Routine inspection·September 28, 2022

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with caregiver Saleem Ansari and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed: Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with caregiver Saleem Ansari, and reviewed the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels, and hand washing guides are posted. Upon entering the facility, LPA Colvin observed postings for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns) which LPA Colvin observed to be sufficient for a 30-day supply. LPA Colvin went over the various recommended training for facility staff with caregiver Saleem Ansari in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. Caregiver Saleem Ansari confirmed that all staff have been fit tested for N95 masks. LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Caregiver Saleem Ansari confirmed that staff are continuing to monitor residents’ symptoms, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility, which LPA Colvin confirmed through being screened upon entry as well. LPA Colvin was shown a temperature log which had record of temperature checks for residents, staff, and visitors. Other: LPA Colvin observed a baby monitor/video camera set up in one resident's (R1) bedroom, and a monitor in the kitchen. The staff confirmed that they use this to check on the resident. LPA Colvin inquired as to if this was per the resident's family's request, but the staff only stated that they purchased the monitor themselves. Deficiency cited. Based on observations made and interviews conducted, the facility was cited a deficiency. An exit interview was conducted with caregiver Saleem Ansari and a copy of this report, LIC 809D, and appeal rights was provided.