Facility Evaluation Report

At approximately 9:55 AM on 02/03/22, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection using the Infection Control Domain of the Compliance and Regulatory Enforcement (CARE) Tools. LPA met with staff and later Administrator and disclosed the reason for the visit.

Entry: At the front door, LPA observed 4 signs related to COVID-19. The signs pertained to the facility’s visitation policy, masking requirement, and COVID prevention policies.

Screening: Upon entering the one, main entry point, LPA was screened by staff for COVID-19. Staff took LPA’s temperature, and LPA submitted contact tracing information in a visitor log. On the screening table, LPA observed 4 boxes of N95 masks, 2 boxes of surgical masks, and a digital thermometer. LPA recommended the facility record symptom and temperature information in the log too. Administrator created a new log for the symptom screening information during the inspection.

At approximately 10:11 AM, LPA conducted a physical plant tour.

Dining Room: LPA observed a fully charged fire extinguisher and a first aid kit near the kitchen. A medication cabinet with client medications was locked. Signs hung near the entrance and dining room pertaining to symptoms of COVID-19, cleaning practices, cough etiquette, droplet precautions, and handwashing reminders. LPA also observed postings for client personal rights, and activity schedule, house rules, grievance procedures, and a confidential complaint hotline.

Kitchen: LPA observed clean floors, walls, and ceilings in the kitchen and dining area. LPA recommended a handwashing instruction sign be placed near the kitchen sink.