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 Michael Curry and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. 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 Michael Curry, and discussed the facility's Mitigation Plan. LPA Colvin informed the Administrator that Licensing does not have a copy of this document, but that a new Infection Control Plan is required and advised the Administrator to review the recent Provider Information Notices (PINs) for direction. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. Upon entering the facility, LPA Colvin had her temperature taken and signed in on the visitor log. LPA Colvin viewed the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns). LPA Colvin did not observe the facility to have isolation gowns. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection as these items are only required if the facility has a COVID positive resident. The PPE supplies that the facility does have are accessible to staff in the staff room. LPA Colvin went over the various recommended training for facility staff with Administrator Michael Curry 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.

Administrator Michael Curry informed LPA Colvin that staff have not yet been fit tested for N95 masks. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Administrator Michael Curry confirmed that staff are continuing to monitor residents’ symptoms.