Facility Evaluation Report

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 Administrator Maryrose Kahn and advised of the purpose of the visit, and that the Annual Inspection will be focused on Infection Control. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Maryrose Kahn. LPA Colvin inquired as to if the facility has a COVID-19 Mitigation/Infection Control Plan, as Licensing does not have one on file. Administrator Maryrose Kahn stated that she believes that they have one, but did not have a copy of it on hand. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note today for the facility not having an Infection Control Plan on file or having submitted one to Licensing. Residents have hand sanitizer available to them, resident bathrooms were stocked with hand soap and paper towels. LPA Colvin observed the bathroom in resident room #3 to have paper towels and hand soap. While touring the facility, LPA Colvin did not observe any postings for cough etiquette, social distancing, or infection control. Additionally, there was no signs on the door regarding caution for COVID-19 symptoms or mandatory masks required. LPA Colvin will be issuing a TA Advisory Note for the lack of informational postings, as they are still recommended at this time. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which was located in the facility garage and is an adequate supply of PPE. LPA Colvin went over the various recommended training for facility staff with Administrator Maryrose Kahn 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.

LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Maryrose Kahn informed LPA Colvin that at this time staff have not. LPA Colvin will be issuing a TA Advisory Note during today's inspection for staff not being fit tested for N95 masks.