Routine inspection (multi-day)·October 24, 2024

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct an annual continuation visit, as well as a concurrent case management visit. Upon arrival, the LPA met with Interim Administrator Laken Lacy. Entrance interview conducted. This visit and related report serve as the annual continuation, legal non-compliance, and case management - incident visit. The purpose of today’s legal non-compliance visit is to ensure the facility is maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. The last legal non-compliance visit took place on 08/01/2023. Upon arrival, LPA met with Interim Administrator and further discussed an incident report that was sent to Community Care Licensing on 09/04/2024, although it was not received and discussed until an unrelated visit at the facility on 10/16/2024. The incident report relates to an allegation made by Resident #1 (R1)'s private companion on 09/03/2024. However, the report referred to an allegation of sexual abuse R1's private companion stated they first observed in March 2024. The facility provided LPA with additional documentation relating to R1, including but not limited to suspected abuse report and medical documentation. R1's family member, who is a medical professional, had R1 tested and no evidence of sexual abuse was found. At the time of the alleged observation/suspicion of abuse, R1 had been diagnosed with a UTI. R1 does have a diagnosis of dementia, so R1 is unable to coherently verbalize any concerns. Interim Administrator stated that following the allegation, both of R1's private companions were provided coaching on timely mandated reporting. After reviewing all information obtained, should a further visit be warranted, LPA will follow up with the facility. Report Continued on LIC 809-C PHYSICAL PLANT: Beginning at 10:51AM, the LPA and the Interim Administrator briefly toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. During facility tour, staff were observed engaging with residents in activities. LPA spoke with various residents throughout the facility tour and no concerns were observed nor communicated. Fire extinguishers throughout the community were observed to be fully charged and last serviced 09/19/2024. FOOD SERVICE: LPA observed the facility's commercial kitchen, which was locked and inaccessible to residents in care. Kitchen appeared to be clean and appliances operable. Facility has sufficient supply of both perishable and non-perishable food, along with emergency food and water. The facility has a system for special diets, including a visual board and diet cards to ensure residents' special diets and dietary preferences are recognized. Storage for chemicals is separate from food storage, per regulation. MEDICATION REVIEW: Began at 11:20AM, LPA, Interim Administrator, along with facility nurse, reviewed medications for 3 (three) residents. All 3 (three) of 3 (three) residents' medications reviewed were stored and documented in compliance with regulation at the time of the visit. FILES: Beginning at 12:06PM, the LPA reviewed a selection of 5 (five) staff files for documents including, but not limited to: health screening, TB test results, background clearance, and training records. All staff records reviewed were observed to be complete and in compliance with regulation at this time. The LPA reviewed 5 (five) resident files for but not limited to: physician's report, needs and service appraisals, personal rights. All 5 (five) resident files reviewed contained all required documents. EMERGENCY DISASTER PLAN: LPA reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually as required. The facility conducts emergency disaster drills on each shift quarterly, with the last disaster drill documented on 09/27/2024. No citations issued. Exit interview conducted. A copy of today's report was provided.