Routine inspection·October 14, 2021

Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and explained the purpose of the visit with Administrator (ADM) Lailo Matias. LPA inspected the facility inside and outside. All of the staff and residents were fully vaccinated. LPA observed screening station located near the front entrance with a 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 signs posted in common areas to promote hand washing and physical distancing. Facility documents daily temperatures for staff and residents. However, LPA observed that 0 of the 2 staff present upon entering facility wearing face masks. When ADM arrived, she was wearing a face mask. ADM is the designated Infection control leader. LPA discussed the mitigation plan with her, as well as their current COVID-19 infection control practices, and though ADM said that they had conducted staff training on infection prevention, symptoms, transmission, as well as the proper donning and doffing of PPE, they were not following a whole host of Infection Control practices, including: - Not following PIN 21-40-ASC with Visitor COVID-19 Vaccination verification from any of the visitors who entered the facility while LPA was present. - Only documenting temperature and not general well-being of residents. - No designated visitation area. - Did not have cough etiquette reminders posted. - Not aware of positive COVID-19 practices and procedures. - No procedures developed for accepting back residents following discharge from hospital. - FIT testing not completed nor scheduled. - Only had a PPE supply for less than one week. - Daily changes in resident health status not being recorded. -------Continued on 809-C----------- 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 in June 2021 and the Smoke and Carbon monoxide detectors were fully operational. LPA observed three (3) Type A deficiencies and two (2) Type B deficiencies, the details of which are in the LIC809-D citations. Exit interview was conducted and a copy of this report and copies of the Appeal Rights were provided.