Routine inspection·February 23, 2022

At approximately 9:00AM, Licensing Program Analysts (LPAs) Willis and Felias arrived unannounced to conduct an Annual required Inspection and met with Administrator, Maria Cortes. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPAs temperatures were checked and documented. LPAs conducted a walk-through of the facility and observed the following: Facility had face mask posters throughout the facility including at the entry way and hand washing signs in the bathroom. LPAs discussed with Administrator to add more signs regarding social distancing and cough etiquette. Based on review of Staff Temperature Log, staff have not documented their COVID-19 screenings for today. Administrator was reminded that staff are to screen at the beginning of each shift. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was available in common areas. LPAs observed staff wearing masks during this visit. Residents are encouraged to wear masks while in common areas. Commonly touched surfaces are disinfected three times a day by housekeeping and caregivers on Noc Shift. LPAs confirmed that housekeeping in Assisted Living works 7 days/week and Housekeeping in Memory Care works 5 days/week. Caregivers in Memory Care sanitize when Housekeeping is unavailable. LPAs and Administrator discussed resident activities and visitation. Continued on LIC809C. Continued from LIC809. Facility has at least a 30 day supply of Personal Protective Equipment (PPE) including surgical masks, gloves, gowns, and hand sanitizer. Per conversation with Maintenance Director, Fire Extinguishers were serviced within the last month however the tags were not updated. Maintenance Director will follow up. Service logs for fire alarms and carbon monoxide detectors were reviewed. LPAs followed up on 3 incident reports where residents passed away but were not on Hospice. No deficiencies cited during this inspection