HELPING HANDS HOME LIVING LLC

A first initial revisit was completed on 5/16/24 for the previous deficiencies cited on 4/3/24. The residence is in compliance with all regulations surveyed.

A first initial revisit was completed on 5/16/24 for the previous deficiency cited on 4/3/24. The residence is in compliance with all regulations surveyed.

An initial certification of the mental health transitional living program was completed on 4/3/24. Deficiencies were cited. The residence was comprised of a North building and a South building.

8.484.3. A All HCBS Settings must have all of the following qualities and protect all of the following individual rights, based on the needs of the individual as indicated in their Person-Centered Support Plan, subject to the Rights Modification process in Section 8.484.5:3. The setting ensures an individual ' s rights of privacy, dignity, and respect, and freedom from coercion and restraint. Based on observation and interview, the setting (residence) failed to ensure the right of privacy to all individuals (residents) who would be served by this setting. Findings include:During the environmental tour on 4/1/24 from approximately 12:15 p.m. to 3:00 p.m. and on 4/2/24 from approximately 11:15 a.m. to 12:00 p.m. with the administrator and department representative #1, the following interviews and observations revealed the residence failed to ensure a design for adequate privacy for residents who would reside in double occupancy rooms. This included that resident access to toilets, room entrance, windows and other shared common areas was not restricted. On 4/1/24 at approximately 12:20 p.m., the administrator stated the residence was requesting licensure as a mental health transitional living setting for 16 beds in both the South and North buildings, totaling 32 beds.a. South buildingThe administrator stated Rooms 1, 2, 3, 7 and 11 were designated as double occupancy rooms in the South building. He stated each room had a private, shared bathroom for two residents' use. He stated that he intended for residents to be first admitted to the North building and that the South building was not yet ready for residents to move in.i. Room 1There was no privacy curtain in the room, although a privacy curtain track was installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room and the bathroom. The second resident side of the room had the only window in the room. This arrangement would not have allowed adequate privacy required for two potential residents. Even when the residence installed a privacy curtain, both potential residents would still not have access to the room entrance, bathroom, and window without physically encroaching upon the private space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the potential residents' respective space as each resident may desire.ii. Room 2A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room and the bathroom. The second resident side of the room had the only window in the room. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance, bathroom, and window without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the potential residents' respective space as each resident may desire.iii. Room 3A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room and the bathroom. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance and bathroom without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire.iv. Room 7A privacy curtain hung from the privacy curtain track installed on the ceilingwhich created two separate areas for double occupancy. One resident side of the room contained the entrance to the room and the bathroom. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance and bathroom without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire.v. Room 11 A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room. The second resident side contained the entrance to the bathroom. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance and bathroom without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire.b. North building The administrator stated Rooms 1, 2, 3, 7 and 11 were designated as double occupancy rooms in the North building. He stated each room had a private, shared bathroom for two residents' use.i. Room 1A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room and the bathroom. The second resident side of the room had the only window in the room. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance, bathroom, and window without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire.ii. Room 2There was no privacy curtain in the room, although a privacy curtain track was installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room and the bathroom. The second resident side of the room had the only window in the room. This arrangement would not have allowed adequate privacy required for two potential residents. Even when the residence installed a privacy curtain, both potential residents would still not have access to the room entrance, bathroom, and window without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire.iii. Room 3A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire.iv. Room 7A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room and the bathroom. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance and bathroom without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire.v. Room 11A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room. The second resident side contained the entrance to the bathroom. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance and bathroom without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire. The administrator confirmed that the manner in which the residence installed the privacy curtain tracks for all 10 double occupancy rooms in the South and North buildings would not allow each potential resident access to the window, bathroom and/or entrance to the room without physically encroaching upon the space of the other resident. He confirmed the room configuration would not provide privacy to both residents. An email from department representative #1, dated 4/2/24, read, in part: "Based on the sizes of the (resident) rooms ... This means that the curtains cannot obstruct the ... access to the toilet or closet/wardrobe or entrance to the room."An email from department representative #2, dated 4/2/24, read, in part: "As long as the window, bathroom, closets, etc. can be accessed by either occupant (resident) without encroaching into the 60 square foot space of the other one, then it's fine." c. Adjoining common full bathrooms - North and South buildingsA sliding door connected two adjoined full common bathrooms in both the South and North buildings. In both the South and North buildings, the locking mechanisms were not functional. Therefore, a resident's privacy while in one of the adjoined full bathrooms was not protected from any other individual entering from the adjoined bathroom. Both the administrator and the director of maintenance confirmed the above observations and confirmed the residence could not guarantee the residents' right to privacy without a functional locking mechanism.

8.495.6 PROVIDER ROLES AND RESPONSIBILITIESI. Staffing Requirements 1. Each facility will divide the 24-hour day into two 12-hour blocks which will be considered daytime and nighttime. The designation of daytime and nighttime hours shall be permanently documented in facility policy and disclosed in the written resident agreements. In determining appropriate staffing levels, the facility shall adjust staffing ratios based on the individual acuity and needs of the participants in the facility. At a minimum, staffing must be sufficient in number to provide the services outlined in the Care Plans, considering the individual needs, level of assistance, and risks of accidents. A staff person can have multiple functions, as long as they meet the definition Direct Care Staff defined at , Sections 8.495.1. Staff counted in the staff-participant ratio are those who are trained and able to provide direct services to participants. Based on record review and interview, the setting failed to ensure the resident agreement's staffing policy included how the two 12-hour blocks were identified, affecting all individuals who would be served by this setting. Findings include:The administrator provided the resident agreement which included the staffing policy; however, the policy did not include how the setting identified the two 12-hour blocks. On 4/2/24 at approximately 12:00 p.m., the administrator acknowledged the setting failed to identify how it identified the two 12-hour blocks in the resident agreement's staffing policy.

An initial licensure survey was completed on 4/3/24. A deficiency was cited. The residence was comprised of a North building and a South building.

1.2 Assisted living residences, as defined herein, shall comply with all applicable federal and state statutes and regulations including, but not limited to, the following:(A) This Chapter 7;(B) 6 CCR 1011-1, Chapter 2, General Licensure StandardsBased on observation, interview and record review, the residence failed to be in compliance with all applicable regulations. This failure created the potential for mismanagement of the care of and services for the residents who would be served by this residence. Findings include:1. Resident's rights to privacy under Chapter II regulations for Facility Guidelines Institute (FGI) and Chapter VII6 CCR 1011-1 Chapter 2 Regulations -1.25 "FGI Guidelines" means the Guidelines for Design and Construction of Hospitals, Guidelines for Design and Construction of Outpatient Facilities, and Guidelines for Design and Construction of Residential Health, Care, and Support Facilities, published by the Facilities Guidelines Institute.-1.28 "Guideline compliance review" means the review of design documents submitted to the department, in the format required by the Department, for determination of compliance with FGI Guidelines.-3.2.3 For any construction or renovations of a facility or agency initiated on or after July 1, 2020, the following requirements of the 2018 Editions, Facilities Guidelines Institute (FGI) including any errata and guideline interpretations adopted as of November 1, 2019, are incorporated by reference, as applicable to facility or agency license type:(C) for residential facilities, including but not limited to Assisted Living Residences, Behavioral Health Entities, Facilities for Persons with Developmental Disabilities, Nursing Care Facilities, and Hospice care: Guidelines for Design and Construction of Residential Health, Care, and Support Facilities.-3.2.4 Facilities and agencies are expected to maintain the facility to the FGI Guidelines under which the Department approved the facility ' s or agency ' s initial license until such time as a new guideline compliance review occurs as required by this Part 3.-3.6 No approval of, or failure to review design documents by the Department shall relieve the owner, developer, designing architect, or engineer of their respective responsibilities for compliance with applicable laws, rules, or codes respecting fire prevention, fire protection, building construction safety, and the FGI Guidelines.-FGI Section 4.1-2.2.2.4(1) reads that visual privacy shall be provided for each resident in multiple-bed rooms.-FGI Section 4.1-2.2.2.4(2) reads that the design for privacy shall not restrict resident access to the toilet, room entrance, window, or other shared common areas in the resident room. 6 CCR 1011-1 Chapter 7 Regulations-13.1 The assisted living residence shall adopt, and place in a publicly visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items: (A) The right to privacy.-22.17 Each sleeping room shall have at least one window of 8 square feet which shall have opening capability.(A) An assisted living residence initially licensed prior to January 1, 1992, is permitted to have a window of smaller dimensions unless the ALR undertakes renovation or changes ownership, at which time the newer, more stringent requirement shall apply. During the environmental tour on 4/1/24 from approximately 12:15 p.m. to 3:00 p.m. and on 4/2/24 from approximately 11:15 a.m. to 12:00 p.m. with the administrator and department representative #1, the following interviews and observations revealed the residence failed to ensure the design for privacy for residents who would reside in double occupancy rooms including that resident access to toilets, room entrance, windows and other shared common areas was not restricted. On 4/1/24 at approximately 12:20 p.m., the administrator stated the residence was requesting licensure for 16 beds in both the South and North buildings, totaling 32 beds.a. South buildingThe administrator stated Rooms 1, 2, 3, 7 and 11 were designated as double occupancy rooms in the South building. He stated each room had a private, shared bathroom for two residents' use. He stated that he intended for residents to be first admitted to the North building and that the South building was not yet ready for residents to move in.i. Room 1There was no shared common area in the room. There was no privacy curtain in the room, although a privacy curtain track was installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room and the bathroom. The second resident side of the room had the only window in the room. This arrangement would not have allowed adequate privacy required for two potential residents. Even when the residence installed a privacy curtain, both potential residents would still not have access to the room entrance, bathroom, and window without physically encroaching upon the private space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the potential residents' respective space as each resident may desire.ii. Room 2There was no shared common area in the room. A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room and the bathroom. The second resident side of the room had the only window in the room. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance, bathroom, and window without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the potential residents' respective space as each resident may desire.iii. Room 3There was no shared common area in the room. A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room and the bathroom. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance and bathroom without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire.iv. Room 7There was no shared common area in the room. A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room and the bathroom. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance and bathroom without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire.v. Room 11There was no shared common area in the room. A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room. The second resident side contained the entrance to the bathroom. This arrangement would not haveallowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance and bathroom without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire.b. North building The administrator stated Rooms 1, 2, 3, 7 and 11 were designated as double occupancy rooms in the North building. He stated each room had a private, shared bathroom for two residents' use.i. Room 1There was no shared common area in the room. A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room and the bathroom. The second resident side of the room had the only window in the room. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance, bathroom, and window without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire.ii. Room 2There was no shared common area in the room. There was no privacy curtain in the room, although a privacy curtain track was installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room and the bathroom. The second resident side of the room had the only window in the room. This arrangement would not have allowed adequate privacy required for two potential residents. Even when the residence installed a privacy curtain, both potential residents would still not have access to the room entrance, bathroom, and window without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire.iii. Room 3There was no shared common area in the room. A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire.iv. Room 7There was no shared common area in the room. A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room and the bathroom. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance and bathroom without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire.v. Room 11There was no shared common area in the room. A privacy curtain hung from the privacy curtain track installed on the ceiling which created two separate areas for double occupancy. One resident side of the room contained the entrance to the room. The second resident side contained the entrance to the bathroom. This arrangement would not have allowed adequate privacy required for two potential residents. Therefore, with the privacy curtain at any position (open or closed), both potential residents would not have access to the room entrance and bathroom without physically encroaching upon the space of the other resident. Additionally, this arrangement would not allow complete visual privacy on all sides of the residents' respective space as each resident may desire. The administrator confirmed that the manner in which the residence installed the privacy curtain tracks for all 10 double occupancy rooms in the South and North buildings would not allow each potential resident access to the window, bathroom and/or entrance to the room without physically encroaching upon the space of the other resident. He confirmed the room configuration would not provide privacy to both residents. An email from department representative #1, dated 4/2/24, read, in part: "Based on the sizes of the (resident) rooms, there doesn't appear to be an opportunity to provide a shared common area. This means that the curtains cannot obstruct the view of the window or access to the toilet or closet/wardrobe or entrance to the room."An email from department representative #2, dated 4/2/24, read, in part: "As long as the window, bathroom, closets, etc. can be accessed by either occupant (resident) without encroaching into the 60 square foot space of the other one, then it's fine." The email further read that the department notified architects during the FGI review process that despite the rule which required facilities to provide double occupancy rooms with a minimum of 60 square feet per resident, it was not physically possible that a room of exactly 120 square feet intended for double occupancy would meet the rule requirements (based on room design; location of window[s], bathroom, closets/wardrobe). (See below, 9. Resident Sleeping Rooms)c. Adjoining common full bathrooms - North and South buildingsA sliding door connected two adjoined full common bathrooms in both the South and North buildings. In both the South and North buildings, the locking mechanisms were not functional. Therefore, a resident's privacy while in one of the adjoined full bathrooms was not protected from any other individual entering from the adjoined bathroom. Both the administrator and the director of maintenance confirmed the above observations and confirmed the residence could not guarantee the residents' right to privacy without a functional locking mechanism. 2. Minimum Services-12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents:(A) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population. During the environmental tour on 4/1/24 from approximately 12:15 p.m. to 3:00 p.m., the following interviews and observations revealed:a. South building i. Adjoining common full bathrooms. There was a sliding door connecting two full common bathrooms. There was a mop in one of the showers in the common bathroom. The floors, toilets, sinks and mirrors in both common bathrooms were dirty and required cleaning. The administrator confirmed staff should have removed the mop and cleaned the bathrooms.ii. Single common full bathroom. The toilet and shower floor were dirty and required cleaning. iii. Resident roomsRoom 4. The toilet bowl was dirty and required cleaning. Room 5. The bathroom floor, toilet bowl and lid were dirty and required cleaning. The window in the room was cracked, creating a potential hazard of broken glass. Room 6. The bathroom mirror was dirty and required cleaning. Room 7. The window screen was ripped, creating the potential for rodent and insect infestation through the opening which measured approximately one inch by four inches. Rooms 8 and 9. The toilet bowl and toilet seat were dirty and required cleaning. Room 11. The toilet bowl was dirty and required cleaning. The director of maintenance confirmed the bathrooms were dirty and required cleaning. He confirmed the cracked window in Room 5 was a potential hazard and that the window screen was ripped in Room 7. iv. Sections of the exterior pavement in the walkway leading to the front door were eroded, creating a potential trip hazard. There were several areas which included measurements of approximately one inch by one inch and approximately three inches by five inches. The administrator confirmed the identified areas were a potential trip hazard.b. North buildingi. Adjoining common full bathrooms. The floors, toilets, sinks and mirrors in both common bathrooms were dirty and required cleaning. The administrator confirmed the bathrooms needed to be cleaned.ii. Resident roomsRooms 2, 4, 9, 10. The toilet bowls were dirty and required cleaning. c. Exterior backyardThere were multiple areas of the walking path that had a difference in surface depth of approximately one inch, causing a potential trip and fall hazard. The administrator and the director of maintenance confirmed there were bathrooms in both the South and North buildings that were dirty and required cleaning. The administrator confirmed the trip hazards in the exterior backyard. 3. Lift Assistance -12.17 The assisted living residence shall ensure that it has trained staff available to evaluate residents who have fallen or are otherwise unable to independently get up off the floor and provide lift assistance when determined appropriate instead of relying on emergency medical responders.(C) The assisted living residence shall promptly notify the resident ' s practitioner, family and/or legal representative of the occurrence of either circumstance identified in Part 12.17(B)(1) or (2), along with information regarding the ALR ' s response. The administrator provided the Fall & Lift policy; however, the policy did not address the timeframe requirement that the residence promptly notify the practitioner and family and/or legal representative. On 4/2/24 at approximately 12:00 p.m., the administrator acknowledged the policy did not include the requirement. 4. Physical Space and Equipment-12.32 Each assisted living residence shall provide sufficient recreational equipment and supplies to meet the needs of the resident engagement program. Special equipment and supplies necessary to accommodate persons with special needs shall be made available as appropriate. When not in use, recreational equipment and supplies shall be stored in such a way that they do not create a safety hazard. During the environmental tour on 4/1/24 from approximately 12:15 p.m. to 3:00 p.m., there was no evidence of recreational equipment and supplies to meet the needs of the resident engagement program. On 4/1/24 at approximately 2:30 p.m., the administrator stated the residence did not have any available equipment and supplies to meet the needs of the resident engagement program. 5. Internal Grievance and Complaint Resolution Process-13.10 Each assisted living residence shall develop and implement an internal process to ensure the routine and prompt handling of grievances or complaints brought by residents, family members, or advocates. The process for raising and addressing grievances and complaints shall be placed in a visible on-site location along with full contact information for the following agencies:(A) The state long-term care ombudsman and local ombudsman. During the environmental tour on 4/1/24 from approximately 3:20 p.m. to 3:25 p.m. and again on 4/2/24 from approximately 11:15 a.m. to 12:00 p.m., the Grievance Procedures policy was posted in both the South and North buildings. However, both postings listed only one "ombudsman" with one phone number. On 4/2/24 at approximately 12:00 p.m., the administrator confirmed the postings did not contain both the state long-term care ombudsman and local ombudsman contact information as required. 6. Exterior Environment -21.2 Slopes and hazards behind the North building. During the environmental tour on 4/1/24 from approximately 12:15 p.m. to 3:00 p.m., the following was observed behind the North building. There was a V-shaped slope in the grassy yard that created a tripping hazard. On 4/1/24 at 2:41 p.m., the administrator confirmed the observation and that it was a potential tripping hazard. 7. Resident Rooms' Bathrooms -22.20 A full bathroom shall contain the following:(D) Private individual storage for resident personal effects.-FGI Section 4.1-2.2.2.5 reads that hand-washing stations in resident bathrooms are required to meet the requirements as specified in Section 2.4-2.2.8. Section 2.4-2.2.8.1(4) reads that the design of hand-washing stations shall not permit storage in casework beneath the sink basin or to areas below a sink open to the floor. -FGI Section 4.1-2.2.2.7(1)(d) reads that private individual storage for the personal effects of each resident is required. During the environmental tour on 4/1/24 from approximately 12:15 p.m. to 3:00 p.m. and on 4/2/24 from approximately 11:15 a.m. to 12:00 p.m., with the administrator and department representative #1, the following interviews and observations revealed:The administrator stated Rooms 1, 2, 3, 7 and 11 were designated as double occupancy rooms in both the South and North buildings. In each of the 10 double occupancy rooms, there was a single storage cabinet space under each room's shared bathroom sink. However, there was no evidence of private individual storage with rounded corners in contrasting colors for each potential resident's personal effects. The administrator stated the single storage cabinet under each room's shared bathroom sink was the only available bathroom storage space for both potential residents who shared a double occupancy room. He stated he was unaware of the requirement. An email from department representative #1, dated 4/2/24, read in part: "Per FGI Sections 4.1-2.2.2.5 the hand-washing station in the resident bathroom is required to meet the requirements as specified in Section 2.4-2.2.8. Section 2.4-2.2.8.1(4) states that the design of hand-washing stations shall not permit storage in casework beneath the sink basin or to areas below a sink open to the floor. In the resident bathroom, section 4.1-2.2.2.7(1)(d) does require private individual storage for the personal effects of each resident. It then says the Casework, Millwork, and Built-Ins for this storage needs to meet the requirements in Section 2.4-2.4.2 that the casework in the resident use areas, the corners should be rounded or eased. So if they (the residence) intend to buy the over the toilet storage cabinets they mentioned, they will need to make sure the corners are rounded or eased. They will also need to be provided in contrasting colors than the walls, and the hardware needs to be contrast value to the cabinet itself. This is so that residents can easily see the cabinet and the hardware to open the cabinet is easily visible as well." -22.22 Toilet seats do not have a cleanable surface that can be sanitized. During the environmental tour on 4/1/24 from approximately 12:15 p.m. to 3:00 p.m., the following was observed:a. South building. Rooms 4, 5, 7, 8, and 9 and the single common full bathroom. The toilet seat surfaces were not intact, creating surfaces that were not able to be sanitized.b. North buildingRooms 1, 3, 9, 10. The toilet seat surfaces were not intact, creating surfaces that were not able to be sanitized. The director of maintenance stated he was not aware of the regulation's requirement. 8. Smoking-22.37 Designated outdoor smoking areas shall have fire resistant waste disposal containers. During the environmental tour on 4/1/24 from approximately 12:15 p.m. to 3:00 p.m., the administrator stated the designated outdoor smoking area for each building was in the backyard. However, there was no evidence of fire resistant waste disposal containers in the backyard. The administrator confirmed the residence had not supplied the residence's smoking areas with fire resistant waste disposal containers as required. 9. Resident Sleeping Rooms -FGI Section 4.1-2.2.2.8(1) reads that each resident shall be provided an individual wardrobe or closet.-22.15 Sleeping rooms, exclusive of bathroom areas and closets, shall have the following minimum square footage:(A) 100 square feet for single occupancy, and(B) 60 square feet per person for double occupancy.-22.16 Each resident shall have storage space, such as a closet, for clothing and personal articles.-22.18 In assisted living residences that provide furnishings for residents pursuant to a resident agreement, each resident shall be provided, at a minimum, with the following items:(B) A standard-sized chair in good condition. A sample resident agreement, provided on 4/2/24, read in part: "Residents are encouraged to bring furnishings from their personal home in order to personalize their room. However, if requested by the Resident (the) Facility (residence) will provide bedroom furnishings including but not limited to a ... chair and dresser, and a way to secure personal items. The furnishings provided by Facility will be the property of Facility, and will stay with the Facility should the Resident vacate the Facility."On 4/1/24 at approximately 12:20 p.m., the administrator stated the residence was requesting licensure for 16 beds in both the South and North buildings, totaling 32 beds. The administrator stated that the residence designated Rooms 1, 2, 3, 7 and 11 as double occupancy rooms in both the South and North buildings. During the environmental tour on 4/1/24 from approximately 12:15 p.m. to 3:00 p.m. and on 4/2/24 from approximately 11:15 a.m. to 12:00 p.m. with the administrator and department representative #1, the following observations revealed:a. South building Rooms 1, 2, 3, 7 and 11 contained only one dresser and only one closet. There were no wardrobes. b. North buildingRooms 1, 2, 3, 7 and 11 contained only one dresser and only one closet. There were no wardrobes. An email from department representative #1, dated 4/2/24, read, in part: "A dresser does not meet the definition of a wardrobe or closet ... The definition of a wardrobe is that it should have an adjustable-height bar for hanging clothes. A dresser does not meet that definition. Also, the square footage requirement per person is exclusive of the bathroom areas and closets. The wardrobe should not be included in the 60 SF (square foot) calculation, as noted in 6 CCR 1011-1 Chapter 7 22.15. Unfortunately, what was provided on the (floor) plans (during FGI review) in regards to creating two closets in the existing closet space is not what they (the residence) have done in the resident rooms. Also, 6 CCR 1011-1 Chapter 7 22.18(B) requires a standard-sized chair in good condition be provided for each resident in the resident sleeping rooms. I didn't notice any chairs in the rooms."10. Handrails and lean rails -FGI Section 4.1-5.2.2.10 reads that handrails and lean rails are to be provided that meet Section 2.4-2.2.10 requirements. Per Section 2.4-2.2.10.3, "where corridors are defined by walls, handrails (or lean rails where permitted) shall be provided on both sides of all corridors used by residents, participants, and outpatients." Per Section 2.4-2.2.10.4, "A handrail shall be provided for each clear corridor wall length exceeding 12 inches."During the environmental tour on 4/2/24 from approximately 11:15 a.m. to 12:00 p.m. with the administrator and department representative #1, the following observations and interview revealed:There were handrails on only one side of all corridors in both the South and North buildings. The administrator confirmed there were handrails on only one side of all corridors in both the South and North buildings. 11. Soiled Utility Room -FGI Section 2.3-4.2.6.2(2) reads a hand-washing station is required to be located in the soiled utility room. An email from department representative #1, dated 4/3/24, read, in part: "There is not a hand-washing station in either room. That is something that wasn't shown on the (floor) plans (during FGI review)."