Follow-up on corrections·November 7, 2024

Licensing Program Analyst Christi Coppo arrived unannounced to conduct a Case Management - Deficiencies and met with Administrator, Jessica Robles. On 8/6/24 LPA was present at facility in order to conduct an annual inspection and open a complaint investigation. While LPA was present at the facility, LPA observed zero staff present in the Main House and later observed one staff present in the Main House. However, the one staff that was present left to get a snack for a resident leaving zero staff present. Today, on 11/7/24 LPA arrived to the facility to deliver findings on a complaint investigation. Upon arrival, LPA went to the Main House and observed zero staff present. During investigation, LPA reviewed ten [10] out of ten [10] residents’ physician reports and appraisals. The reviewed physician’s reports and/or appraisals indicate that · 9 residents have either wandering behavior or sundowning behavior · 3 are identified as being a fall risk · 10 require assistance (extensive or full) with bathing · 10 require assistance (extensive or full) with dressing and/or grooming · 10 require assistance (extensive or full) with toileting and/or incontinence care · 9 require some type of ambulatory assistance including but not limited to transfer assistance · 3 are unable to feed themselves Continued on 809C... Continued from 809... LPA review of staff schedule indicates that no more than 2 staff are present at the Main House at any given time. The facility is set up as a series of 3 independent cottages (detached and across from the main house) with a main house containing 4 bedrooms. The facility kitchen and laundry are across the driveway from the main house at the end of the aisle of the cottages. This means that staff must leave the main house entirely to get food from the kitchen, do the laundry, and attend to the residents in the cottages. Facility also has locked entrance that requires all visitors be buzzed in, the location of the buzzer was outside of both the cottages and the main house both times LPA visited the facility. This means staff must leave the main house or cottage to permit visitors to enter the facility. Additionally, a staff the takes the visitors' temperature and has them sign in, which also takes time. Based on the care needs indicated by the residents’ respective appraisals and physician’s reports, and the current staff roster and staff schedule, it appears that the facility does not have enough staff to meet the various possible care needs of residents at any one given time ( deficiency cited, see 809D ).