Post-licensing visit·August 13, 2021

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/13/21 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: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. 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. Administrator arrived at the facility. LPA, Administrator, and Infection control Leader completed the infection control domain and facility was found to be in substantial compliance at this time. Licensee will symptom screen staff, residents and visitors, ensure paper towels at all hand washing stations, discussed BiMax program registration, conducting weekly testing for staff not fully vaccinated and will have more trashcans with lids for disposal of masks and gloves. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.