Compassion Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the full care inspection tool. , LPA was greeted by Roberta Morgan, Caregiver, and explained the purpose of the inspection. Caregiver contacted Ana Mariut, Administrator, who arrived at 1:15 pm. . LPA observed a second caergiver, Deloris Wade-Rowe also present during the inspection. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols, wore a surgical mask and was screened per Covid-19 precautionary measures upon entering the facility. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3). Currently there are no residents receiving hospice services. LPA observed (2) residents in the common area and (4) residents to be in their rooms resting at the start of the inspection. LPA and Administrator toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms, (1) shared resident bedroom, (2.5) resident bathrooms, kitchen, office, staff room, laundry area and garage. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels, trash cans with lids and 20-second hand-washing poster. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food and locked sharps and toxins in the kitchen. LPA observed locked medications in the office area. LPA observed sufficient PPE supplies in the garage. LPA observed the inside temperature to be 73*F. The fire extinguisher was last serviced on 1/31/23.. Discussed vaccination status of residents/staff and eligibility for boosters. LPA observed (1) unlocked gate from the inside back patio and a covered patio area with seating. LPA reviewed (2) of (6) resident files and found them to contain current documentation- the care plan was updated recently but is waiting for family signatures. LPA reviewed medication orders to medications administered for these same (2) residents and found no discrepancies. LPA reviewed (4) of (4) staff files and found all staff to be cleared and associated to the facility and to have current First Aid/CPR training and the required initial/ongoing training. Administrator is waiting for an updated copy of RCFE Admin #6016203740- exp 4/17/22. cont on 809C.. 809C(1)... LPA and Administrator reviewed Infection Control Plan and a copy was provided to the Department during today's inspection. LPA observed cameras in the common areas of the facility and all required postings to be posted at the facility. LPA printed an updated copy of the facility license during today's inspection to reflect an approved hospice waiver for (3) residents. LPA requested an updated copy of the LIC308. LIC500 and current liability insurance during today's inspection by 3/17/23. There are no deficiencies issued during today's inspection; however, a Technical Advisory Note is being issued on the LIC9102TA. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Mar 9, 2023

Allegation investigated: Facility staff caused injury to resident Facility staff removed resident’s phone Facility staff failed to safeguard resident belongings

On 8/9/22 , Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with clinical staff. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Upon arrival, completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened for Covid 19 symptoms at the facility. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. R1, who is diagnosed with dementia was unable to provide reliable historical information regarding her phone, belonging or injuries that could be corroborated. Unsubstantiated Residents and facility staff were interviewed and no injuries were witnessed that were the result of a lack of supervision or mistreatment of R1. Reports from family members were at time contradictory of each other regarding R1’s phone and other belongings whereabouts. R1’s records indicate that all injuries were properly reported to R’s physician and power of attorney. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with caregiver.the state’s words, verbatim · CDSS document, Aug 9, 2022 · control 25-AS-20220504122945

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 2/23/22 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Licensee/ Administrator arrived to assist with the visit LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Licensee utilized the infection control guidance and facility was found to be in substantial compliance at this time. LPA advised the following: ensure all staff have fit tested N-95s if needed, maintain records of all staff and visitor vaccination and testing, utilize Guardian to manage associated staff, insure not fully trained staff are not providing unsupervised care and ensure that staff wear recommended masks while in the community.. LPA requested: R1 vaccination record or proof of exemption. Proof of R2 training and staff records. Records to be provided to CCL by Fri., 2/25/22. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Feb 23, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 9/28/21 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Licensee/ Administrator arrived to assist with the visit LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Licensee completed the infection control domain and facility was found to be in substantial compliance at this time. LPA advised the following: ensure all staff have fit tested N-95s if needed. LPA requested: Resident Roster, LIC 500, Administrator's Certificate, last page (signature for annual review) LIC 610E and Liability Insurance. Documents to be submitted to LPA via email by 10/5/21. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Sep 28, 2021