Routine inspection·May 21, 2021

Licensing Program Analyst (LPA) Spencer conducted an unannounced annual inspection visit focusing on the Infection Control Domain. LPA Spencer met with assistant administrator Jeenne De Castro and administrator Joe Goldman and explained the purpose of today's visit. LPA conducted a physical plant tour and inspected the entrance screening area, activity room, one (1) common restroom, dining room, kitchen, five (5) resident rooms/bathrooms, six (6) isolation/quarantine rooms, visitation area, medications room, and supply closet. LPA Spencer observed infection control practices in accordance with the facility's approved mitigation plan. The facility had a entrance screening area with contactless thermometer, hand sanitizer, and screening form. There was COVID-19 signage posted throughout the facility. The activity room furniture was not spaced at least 6 feet apart but dining room furniture was adequately spaced. All staff wore masks and residents were encouraged to wear masks as tolerated. The facility had at least a 30-day supply of PPE. The common restroom, (6) isolation/quarantine rooms, and (5) resident room trash cans did not contain lids. (6) of (6) isolation/quarantine room restrooms did not contain soap and paper towels. A visitor's area was designated and had a sign-in sheet, contactless thermometer, hand sanitizer, and separate entry/exit. During a review of the records, LPA reviewed the resident and staff temperature check log, COVID-19 staff training logs, line list of surveillance testing, emergency contact information for five (5) residents, and medication records for five (5) residents which were all documented accurately. LPA requested a copy of the staff roster, resident roster, and surety bond; all staff had required fingerprint clearances. There were no deficiencies were cited at this time. LPA Spencer conducted an exit interview and a copy of the report was emailed to the administrator and assistant administrator.