Routine inspection·July 22, 2021

Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility at 10:25am to conducted a One (1) year Required Infection Control visit. LPA meet with the Administrator Narine and staff Rena and Elmira and explained the purpose of this visit. A tour of the physical plant was conducted at 10:30am and the following was observed: The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette and physical distancing) posted. The PPE screening station is located in the living room area on a table equipped with sufficient PPE readily accessible, a thermometer, hand sanitizer, gloves, mask and sign in sheet at the time of visit. Visitors are not allowed in the facility. Fire Extinguisher located on the wall next to the kitchen which was purchased from costco on 04/02/2021. At 1:20pm the fire alarm system was tested and observed to be working, it is hard wired through out facility. The smoke detector between room three (3) and four (4) is a carbon monoxide/smoke detector in one (1). The facility First Aid kit is located in the living room in the work desk area. The facility has an approved mitigation plan on file. The facility has four (4) bedrooms and two (2) bathrooms. Three (3) out of four (4) bedrooms are occupied by residents. One (1) hospice resident and waiver for (4) four. All residents are non-ambulatory. (Continued on LIC 809C) Kitchen: The kitchen was observed to be clean and an adequate supply of two (2) day perishables and seven (7) non-perishable food was located in the fridge, freezer and pantry. Food was properly labeled and stored. The emergency food is stored and observed in a pantry in the kitchen. Lunch is served in residents rooms or in the dining area if residents choose. Sharps were observed in the kitchen to be locked and inaccessible to residents. Storage Rooms: LPA observed storage for PPE in the shed in the back yard area, which was observed to be locked and inaccessible to residents. The facility toiletries and incontinent supplies are located in a cabinet near the kitchen/dining area. Linen are also stored in a cabinet near kitchen/dining area and in drawers located in the living room area and also in a cabinet between room one (1) and two (2). Client Rooms: Resident in room one(1) is a hospice client and has a Plan of Care dated 3/19/2021 from Rite Care Hospice with an order for full bed rails. Resident in room three (3) has a physician order from An Hong Trang, MD dated 6/22/2017 for half bed rails. All rooms have adequate furniture and lighting. Medications: The medication room is adjacent to the kitchen which was observed to be locked. Laundry Room: Located adjacent to the kitchen observed to be locked and clean and clear from obstruction. Laundry soap and toxins and cleaning supplies are locked and stored in the laundry room. Living, dining room and common areas: Observed to be appropriately furnished with tables and chairs and adequate lighting. The facility maintains a comfortable temperature at 74 degree Fahrenheit. Observed to be neat and clean. The bathroom: Observed to be clean and proper operation. LPA observed the appropriate grab bars in and around the toilet and shower also non-skid mats are located in the shower area. The water temperature in the bathroom one (1) was 118.1, bathroom two (2) was 118.6. The backyard : Is a covered patio area with tables and chairs for lounging and a storage shed area locked inaccessible to residents which holds PPE is stored and other incontinent items. No bodies of water are located on the premises. Exit interview conducted. Copy of this report issued