Klara's Adult Care Home, LLC

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policy and procedure manual revealed documentation indicating the policies and procedures were last reviewed by the owner on December 15, 2017. No additional documentation was available indicating the policies and procedures were reviewed at least once every three years. 2. In an interview, E1 acknowledged documentation was not available to indicate the facility's policies and procedures were reviewed at least once every three years.

Based on observation and interview, the manager failed to ensure a resident's sleeping area had a window or door that could be used for direct egress to outside the building. The deficient practice posed a risk if residents were unable to safely evacuate the facility in an emergency. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed the shared bedroom for R1 and R3 contained a window. However, two nightstand tables were blocking the window, preventing direct egress. The Compliance Officer also observed the bedroom for R4 contained a window. However, R4's bed was blocking the window, preventing direct egress. Additionally, the Compliance Officer observed the bedroom for R5 contained a window. However, R5's bed was blocking the window, preventing direct egress. 2. In an interview, E1 acknowledged the manager failed to ensure the aforementioned sleeping areas had a window or door that could be used for direct egress to outside the building.