Routine inspection·January 27, 2022

At approximately 1:25 PM on 01/27/22, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Licensee and disclosed the reason for the visit. Census: 104 The facility has 3 floors. The lowest floor contains the kitchen, cafeteria, and outdoor patio. The first floor is the main floor and contains non-ambulatory rooms, a television room, the main entry, and the office. The second floor is designated for ambulatory residents. Floors are accessible through elevator and stair access. At approximately 2:04 PM, Licensee and LPA toured the physical plant. Entry: LPA observed 2 signs on the front door related to COVID-19 precautions for mask requirements and visitation. Screening: LPA was screened for symptoms of COVID-19 and had temperature taken upon entry to the facility. Facility maintains a log tracking visitors’ symptoms, names, and temperatures. When residents return from outings, staff conduct symptom checks and observe for any noticeable changes in condition. Facility uses rapid tests if residents are symptomatic. PPE: LPA observed an office with adequate amounts of N95 masks, surgical masks, sanitizer, gloves, and PCR tests. Bedrooms: The facility has 64 bedrooms. All bedrooms are shared and have a private bathroom. Licensee noted all bedrooms are cleaned three times a day, or as needed. If a resident submits a positive COVID test, the facility has vacant bedrooms to isolate their roommate. Bathrooms: The facility has 8 public bathrooms. LPA observed bathrooms on the first floor which were fully stocked with soap, paper towels, trash cans with tight-fitting lids, and signs with handwashing instructions. Kitchen and Cafeteria: LPA observed staff mopping the kitchen area. The kitchen appeared clean, odorless, and free from debris. The cafeteria has tables which are approximately 6 feet apart from each other. Common Areas: The television room had chairs which were 6 feet apart to promote social distancing. LPA observed 4 signs posted alerting residents to wear masks maintain and 2 signs for social distancing. Licensee noted the television room formerly had couches, but the facility switched to chairs due to COVID-19 mitigation efforts. The facility has 2 elevators, both of which had signs for masking requirements, coughing etiquette, and social distancing. The facility has a social distancing policy for elevators: 2 individuals at a time. LPA observed a free telephone for all residents’ use. LPA observed signs posted throughout hallways on all floors for social distancing, mask wearing, and cough etiquette. Outside Space: LPA observed outdoor areas to be free from obstruction and hazards. All emergency exits were unlocked. Al staff were observed wearing masks. Mitigation: Licensee told LPA that meal times are staggered, and residents have the option to have in-room meal service in which staff can serve trays to resident rooms. In the event of a COVID positive resident, the resident would isolate in their room for a minimum of 5 days. The facility marks the room as a Red Zone, and staff are able to provide meals, medications, cleaning, and supervision to residents in isolation. Meal service is provided with disposable cutlery. All staff are trained in donning and doffing PPE. Licensee informed LPA the facility uses carts to store PPE outside of isolation rooms and trash cans with tight fitting lids remain inside the isolation room. LPA observed a laundry room downstairs near the kitchen, and Licensee noted staff are able to sanitize the machines between loads. The facility coordinates with CVS to provide on-site vaccination and testing.