Routine inspection·October 7, 2021

On 10/7/21, at 9:37 am, Licensing Program Analysts (LPA) Susan Campos and Ngozi Nwaokoro conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was allowed entry into the facility by Carla Mariano, Administrator. LPA met with Ms. Mariano and explained the purpose of the visit. The facility is licensed to operate for ninety-one ( 91) non-ambulatory with (10) may be bedridden, delayed egress on floors 2-8, hospice waiver for 15 residents. The facility is a white high rise 8 story building with a sprinkler system, located in a downtown commercial area. Included in the 8 floor structure is a basement, main floor, memory care community (floors 2,3,4,5) and assisted living community (floors 6,7,8) with a delayed egress at exit points present on floors 2nd – 5th. There are (2) fire extinguishers located on each floor. Water stations are located in the lobby and the dining room of each of the floors. The resident room unit has a smoke detector that are battery operated and one hard-wired and interconnected. Each facility floor has a dining room, staff room which includes a locked medication cart and first aid kit and is inaccessible to the residents and also on each floor is an all gender public restroom available for resident use. LPAs observed Main floor: Lobby, Reception area, and Executive Director office, Basement: Common Area/Activity Room, (3) Gender Neutral Public Restrooms, wall area with notifications and postings of resident rights, house rules and activities, medication room that was locked and inaccessible to the residents that included, magnetic locks on the cabinet, and a medication refrigerator, Laundry room with two commercial washing machines and dryers, supply cabinet with storage of towels, linens, fitted sheets, flat sheets, blankets, mattress pad, mattress covers, storage room contained personal care supplies, Beauty Salon, Activity Room/Art Studio with board games, reading materials and craft supplies, Business Office, Wellness Office, Fitness Room, Staff Lounge, Kitchen and PPE supply room and the Roof-9th floor patio area included string lights, 2 lattice patio covers, 3 umbrellas, and 3 sets of patio tables with chairs . In addition, LPAs inspected 14 resident rooms (#202A, #205, #301B, #304A, #306B, #402A, #405, #504B, #508, #604, #701A, #704, #801, #808 ). There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client Evaluation Report Continues on LIC 809-C personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature was measured for 14 resident rooms and are noted as the following: (#202A-105 F, #205-107.7F, #301B-108.7F, #304A-108.5F, #306B-105F, #402A-105F, #405-110.1F, #504B-107F, #508-107.1F, #604-107.1F, #701A-109F, #704-106.7F, #801-107.1F, #808-109.2F ). A comfortable temperature of 73 degrees was maintained in the facility. The LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. All facility (39) fire extinguishers were checked and are charged, (39) resident room smoke detectors were checked and are operable, and also the facility carbon monoxide detector was checked and is operable. Fire Drills were observed to be maintained in order and accurate. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, and LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed. No deficiencies were cited during this inspection visit. An exit interview was conducted and a copy of this report was provided to Administrator Carla Mariano.