Routine inspection·February 1, 2023

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced required annual visit. Along with the required annual visit, 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. The LPA met with Akeema Matthew, Director of Health Services and Kaitlyn Smith, Director of Resident Family Services and explained the reason for the visit. Executive Director Terri Weitzman was unavailable during today's visit. The last legal/non-compliance visit was conducted 11/01/2022. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Residents were eating at the time of the visit. Dining room furniture appeared to be in good condition. BEDROOMS: The LPA observed a randomly selection of resident rooms, and rooms were furnished appropriately with clean linens, furnishings and sufficient lighting. RESTROOMS: The LPA observed a random selection of resident restrooms. Restrooms were clean, sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms were stocked with soap and paper towels. Water temperature was tested, and temperature ranged from 107.6 – 112 degrees Fahrenheit. Hand washing signs promoting good hand hygiene were observed in the common restrooms. COMMON SPACES: Walls and flooring were checked for cleanliness and good condition. Infection control signs were posted at the entrance and throughout the hallways. Department required postings were found in the front lobby near the restrooms. Fire extinguishers were charged and serviced 9/22/2022. EXTERIOR: The facility has several enclosed courtyards with appropriate outdoor seating for resident use. The swimming pool on the premises was observed to be locked. INFECTION CONTROL: Staff were observed wearing appropriate face coverings. The facility continues to screen visitors and staff upon entry into the facility. The facility has an adequate supply of Personal Protection Equipment (PPE). Hand sanitizer was available for staff, residents and visitors. The facility can designate a section of the facility for isolation and quarantine purposes if the facility has a confirmed case of COVID-19. The facility keeps record of staff and resident vaccinations. LEGAL: As it pertains to the Stipulation and Waiver, and Order, the following was noted: · Career Smart conducting quarterly audits: The last audit took place in December 2022; recommendations were made around organization of staff training, medication procedures, and staffing. · Addendums that specifically discuss identified sexual and/or aggressive behaviors for new admissions continue to be utilized in resident care plans · Compliance audit was conducted by a member of the licensee’s governing board on 11/28/2022 · Facility continues to monitor staffing levels as it relates to resident care needs and census. Facility currently using agency staff to supplement for staffing levels · Staff support group was conducted on 1/30/2023, with a census of 12 staff in attendance. · Resident care needs are assessed monthly · Training documents were observed and compiled; however, the LPA was unable to easily identify if direct care staff had completed the minimum of six (6) hours of quarterly training. Recommendation was for files to be more organized so that the reviewer to confirm whether staff have received the required training. No deficiencies cited at this time. Exit interview conducted. Signatures obtained.