Routine inspection·May 16, 2022

Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by S1 and met with Licensee John Reade, who was informed of the purpose of the visit. At the time of visit there were 3 staff and 5 residents present. The facility currently has zero positive or suspected Covid-19 cases. During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings at the facility and advised licensee to post them throughout the facility. A single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. LPA advised licensee to start documenting these temperatures and to have a sign in sheet for visitors. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all restrooms. LPA advised licensee to place soap in down stairs bathroom. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA observed a sufficient 30-day supply of PPE equipment. LPA advised Licensee to have staff FIT tested for the N95 masks. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces. During the tour of the facility LPA reviewed LIC9020 and advised Licensee to update this after R1 passed away. LPA received a copy of the death report that was e-mailed the the department within 7 days. LPA also advised Licensee to e-mail updated LIC500 as soon as possible. LPA was able to review e-mail from Administration Certification department for Administrator Certification renewal. LPA spoke with Department representative Roshika, and confirmed this information. There were no deficiencies noted at the time of the visit. An exit interview was conducted, and a copy of this report was reviewed and provided to facility licensee, John Reade.