Routine inspection·February 15, 2022

At approximately 9:20 AM on 02/15/22, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection using the Infection Control Domain of the Compliance and Regulatory Enforcement (CARE) Tools. LPA met with staff and disclosed the reason for the visit. Census: 5 Entry: The front yard was maintained and surrounded by an unlocked gate. A ramp led to the facility’s entrance. A sign regarding the facility’s vaccination and masking requirement hung on the front door. The facility had one main entrance designated for screening visitors, staff, and residents. Inside, LPA observed signs for Droplet Precautions, cleaning procedures, handwashing technique, confidential complaints, personal rights of residents, and ombudsman information. Screening: Upon entry, LPA was screened by staff. LPA recorded temperature, symptoms, and contact tracing information in a visitor log. LPA observed a screening station which contained a digital thermometer, symptom questionnaire sheets, surgical masks, N95 masks, face shields, sanitizer, gloves, and rapid test kits. At approximately 9:30 AM, LPA conducted a physical plant tour. Safety: LPA observed Emergency Evacuation Plans with routes clearly labeled in all bedrooms and at the front entrance. All smoke detectors were functioning. Water temperatures tested in Bathroom #1 at 105.5 degrees Fahrenheit. Emergency exits paths were clear and unlocked. Bedrooms: The facility had 5 bedrooms. One bedroom is designated for staff. The staff bedroom was locked and contained no hazardous items. Two resident bedrooms, Bedroom #2 and Bedroom #4 are shared. Resident beds were at least 6 feet apart to accommodate social distancing. Two resident bedrooms, Bedroom #1 and Bedroom #3 are private. All bedrooms contained adequate storage space, clean linens, televisions, nightstands, and lamps. Bedroom#1, Bedroom #2, and Bedroom #3 had exit doors in the room with ramps leading out. Bathrooms: The facility had 2 bathrooms. Bathroom #1 is near the facility entrance and Bedroom #1. Bathroom #2 was between Bedroom #3 and Bedroom #4. Both bathrooms contained fully stocked soap, paper towels, trash can, non-skid mats, and grab bars. Common Area: All common areas were clean. All furniture was in good repair. Seating at the dining table and television area were arranged to accommodate social distancing. All floors and ceilings were clean as well. Kitchen: LPA suggested the vent above the stove be cleaned. The kitchen contained two fridges with adequate supplies of perishable food. Cabinets contained clean dishes, a weekly menu, and adequate supplies of non-perishable food. At the end of the kitchen was a door to the laundry room. The room contained a washer and a dryer, and all detergents and cleaning supplies were in locked cabinets. Office: Near the kitchen, LPA observed a locked office with resident medications, files, and water bottles. Outside space: LPA observed a covered patio area for visitation and an extra table with furniture in good repair. All outdoor spaces and paths were from obstructions. Garage: LPA observed a garage with adequate incontinence supplies and PPE. LPA conducted exit interview and issued report.