Routine inspection·September 30, 2021

Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and explained the purpose of the visit with Administrator TRACEY INGLEMAN . LPA observed all staff wearing face masks during the visit. The Department did not have a copy of their 01/20/2021 mitigation plan, so the LPA reviewed and approved it and then uploaded it to FAS. Ms. Ingleman is the Infection control designated leader. LPA discussed the mitigation plan with administrator, as well as their current COVID-19 infection control practices. Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE. All but 4 staff and 2 residents were fully vaccinated. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with a digital visitor's log, hand sanitizer, face masks, and a no-touch temperature probe. Routine symptom screening (+/-) temperature and symptom check is done at entry for all staff, residents, and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents electronically. Pathways were observed to be free of obstruction and fire hazards. There were sufficient food and water supplies in the kitchen refrigerators/freezers. Emergency paper and PPE supplies were observed. Facility room temperature was maintained at a comfortable temperature. A certified administrator is on site at all times to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguishers were observed fully charged and last inspected on 09/1/21. Smoke and Carbon monoxide detectors were operational. LPA observed the facility is in substantial compliance. No deficiencies are being cited during this inspection. Exit interview conducted and a copy of this report provided.