Routine inspection·February 17, 2022

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 2/17/22 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA were screened by facility staff upon entering the facility. Administrator arrived to assist with the visit. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and designee completed the infection control domain and facility was found to be in substantial compliance at this time. LPA advised the following: locks to cabinets in the kitchen where harmful products are stored, more robust symptom screening, and ensure all staff have fit tested N-95s. LPA and administrator discussed the training, documentation and record keeping for incontinence care plans and wound care and process for medication dispensing if pour by person other that dispensing. LPA requested: Administrator's Certificate and Liability Insurance copies when renewed. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.