Routine inspection·September 22, 2022

On 9/22/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted the assistant administrator, Adrienne Fair and the resident service director, Elizabeth Wyma-Hughes. LPA explained the purpose of the visit and LPA was screened at the front entrance. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies, PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap and paper towels; COVID-19 and hand-washing instructions signs are observed to be posted through-out the facility; garbage cans are observed to be foot operated; hand sanitizers are observed at varies locations. Main PPE supplies are stored in the maintenance shop and it is being managed by the housekeeping supervisor who conducts weekly inventory checks and order supplies accordingly. In addition to the maintenance shop, LPA observed PPE supplies stored in the medication room and the storage room on the 3rd floor where all staff has access to. All residents are being screened for COVID-19 every shift and staff are being screened via Accusheild when they enter the facility. The facility conducted their 3rd booster clinic this week for residents and staff. The facility continued weekly testing for staff as they returned from their day off. Medications are locked in the medication rooms. First aide kits are observed to be equipped in the medication rooms and nursing stations. A comfortable temperature is maintained, lighting is sufficient for comfort. No deficiency cited today. This report is reviewed and discussed with the resident service director and the assistant administrator. A copy is provided.