Routine inspection·December 21, 2022

On 12/21/22, at 8:53 am, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit with a primary focus on Infection Control measures. 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, with a 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 2,3,4,5,6) and assisted living community (floors 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 (great room) on each of the floors, which showed an average hot water temperature at 107.9 F. 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. LPA observed Main floor: Lobby, Reception area, common area and Executive Director office; Basement: Common Area/Activity Room, three (3) Gender Neutral Public Restrooms, wall area with notifications and postings of resident rights, house rules and activities, medication room that is 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 ( PPE supply room is attached), Staff Lounge, Kitchen and food supply room. At the Roof level (9th floor) there is a patio area including string lights, 2 lattice patio covers, 3 umbrellas, and 3 sets of patio tables with chairs. LPA inspected 10 resident rooms and tested the emergency-pull cord in room #507 with the response time at 42 seconds. There were no bodies of water or obstructions on the premises. See LIC 809-C Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit, which are provided by family members and provided by Regency Palms. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature was measured for resident rooms and are noted as the following: Room #807 at 118.2 F, Room #507 at 117 F. A comfortable temperature of 73.1 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 were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and stored properly, with a hot water temperature measured at 139.6 F with notification signs properly posted. All facility (39) fire extinguishers were checked and are charged, last dated 10/22/22, (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, showing the last drill on 12/13/22 . 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 infection control posters were posted. A review of staff and resident temperature logs were reviewed upon entry. 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.