Non-compliance follow-up·August 30, 2022

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Legal Non-Compliance inspection at the facility today. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. Areas discussed: A. Licensee shall operate the facility in substantial compliance with regulations and statures governing the operation of a residential care facility for the elderly. The LPA focused on the physical plant and the infection control protocol. Signs were observed in common areas that promoted guidance around COVID-19, appropriate masking, physical distancing, and the disinfection protocol. The facility continues to monitor the vitals, symptomatic screening, and temperatures of the staff and visitors that come into the community. Hand sanitizer was available throughout the community. Staff were observed wearing appropriate face coverings. The LPA observed residents engaging in group activities, which were led by staff. Activity rooms and common spaces appeared clean and in good repair. Common restrooms were observed, and the LPA observed signs in the restrooms that promoted good hand hygiene. At 9:35 a.m., the hot water measured in the common restroom at 113.1 F. Restrooms were stocked with paper towels and soap. The LPA observed appropriate outdoor furniture in the gated courtyards, with a covered shaded area for residents. The exterior and interior grounds were free of clutter and/or obstructions. The community has a swimming pool, which is locked. B. Career Smart will conduct quarterly audits and have weekly calls with the Administrator. Staff confirmed that weekly calls are still taking place, every Wednesday. The two-day audit last took place on 6/1/2022 and 6/2/2022. Career Smart will be in the community to complete the audit on September 7 th and 8 th . C. Licensee will include specific inquiries regarding sexual behaviors and aggressive behaviors during the initial evaluation of new residents Reappraisals will address sexual behaviors and aggressive behaviors when such conduct is evident . The community has not admitted anyone with these specific behaviors within the past two months, but this addendum is included in the assessment for all residents. D. A member of the licensee’s governing board shall, on a quarterly basis: conduct on site facility visits, review both reports generated by outside consultant and those from CCLD, prepare written reports to the licensee’s governing board, and ensure POCs are completed and submitted timely. On August 9 th , a visit was conducted by Loren B. Shook. E. Department shall conduct quarterly inspection during the probationary period. Today, 8/30/2022. F. Licensee shall provide a thirty-minute overlap of direct care staff between each shift . Staff communicated that the time frame is indicated on the staffing assignments to demonstrate the 30-minute overlap. LPA reviewed staffing sheets to confirm appropriate coverage. G. Licensee shall chart any reportable resident injuries on each shift and communicate such injury to direct care staff prior to initiating their shift. Shift change form was created and is being utilized daily. The nurses sign this form during shift change. H. Licensee shall continue to maintain adequate staffing to meet the specific needs of individual residents in care and population as a whole. Staff are continuing to monitor their staffing numbers. Staffing is reassessed every day, every shift. Agency staff are still being utilized as needed. Additional associates have been added and hiring is ongoing. I. Licensee shall form a client/resident assessment management that consists of the certified administrator, nursing personnel, and supervising/direct care staff who shall meet at least once a month, in order to reassess the appropriateness of continued placement retention or relocation residents to facilities offering a higher level of care. Yes, this took place on 8/29/2022. LPA reviewed meeting minutes. J. Licensee shall conduct a monthly support group facilitated by an outside professional approved by the Department, providing an opportunity for associates to share issues/concerns and have a safe environment for communication and sharing without management presence . Session took place on 8/23/2022. The LPA reviewed the past three months to confirm that sessions have happened monthly. The sessions are two hours - one hour for a group session and one hour for individual check-ins. K. Licensee shall provide direct care staff a minimum of 6 hours of quarterly training on Title 22 regulations ... The facility holds in-service trainings two hours a month, to ensure that hours are all completed for direct care staff. The LPA reviewed training documents to confirm that staff are receiving the required training hours. L. Licensee will designate one employee who is fully trained as a caregiver on all shifts as a float staff. This is indicated on the staff schedule and the daily staffing sheet. M. Licensee shall assign qualified staff to assess residents who lack the cognitive or physical ability to communicate their needs or injuries on a regular basis as determined by their initial care plan. Documentation of the direct care staff’s observation of any newly identified resident needs or injuries, including pressure injuries, shall be reported to the direct care staff’s immediate supervisor on a daily basis and to the Department, when applicable. On a monthly basis, all residents are assessed for any changes in needs. This is in addition to care plan/service plans that are created for residents. The LPA observed that this was completed for July 2022 and is pending completion for August 2022. During today’s visit, the LPA checked to ensure that Staff #1 (S1) was not working at the facility. S1 has not been in the facility since May 2022. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.