Facility Evaluation Report

On this day Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced infection control annual inspection visit. LPA met with facility staff and let him know the purpose of today's visit. Upon entry LPAs temperature was not taken and was not asked COVID questions.

LPA toured the physical plant inside and out. There are no accessible bodies of water or fire safety hazards observed. LPA did observe Lysol disinfectant spray on the floor in the backyard near the door entering the facility. COVID postings are present at front door and through out the facility. Hand washing signs are present in bathrooms. Hand sanitizer is observed as readily available through out the facility. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Medication cabinet is observed as in order and door is locked. First aid kit is observed as in place in kitchen cabinet. Toilet and bathing facilities are equipped with grab bars and some showers equipped with non-slip mats. Liquid soap is available. Paper towels are present for resident use. LPA observed Comet cleaning powder and Lysol disinfectant spray in both bathrooms. Water temperature is taken in both common bathrooms. Front bathroom water temperature is measured at 140F and the rear bathroom the water temperature is measured as 136F. LPA observed 5 resident rooms and all had required furniture, lighting, linens and were in clean condition. Laundry machines and dryers are observed as functioning in the garage. Emergency food supply, dry goods, and perishables are observed as in place. Communal dining are is observed as in order. Fire extinguishers are charged ready for use. There is no inspection tag but according to the dial on the extinguishers observed adjacent to the kitchen and near the rear of the facility they are charged in the green range.

Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place. LPA reviewed training records and they are current. LPA sampled staff first aid cards and training records. Staff first aid cards are not current dated 1/27/2022 expiration date. Per staff person all staff has not had first aid training since the expiration. Training records are not current with the last training taking place in 2020 per staff file reviewed. Resident temperature log are current. Staff indicate they take daily temperatures but there is no log. All staff and residents are vaccinated according to the staff person. Facility only tests residents for COVID if symptoms are present.

A disaster and mass casualty plan is present and current. Criminal record clearances or exemptions for facility staff or other individuals are reviewed. Administrator certificate is not available for review. According to staff the mitigation plan and infection control plans are current.

LPA is requesting the following forms to be updated and sent to the Department by 9/22/2022:

• LIC 308 Designation of Administrative Responsibility

Report is reviewed with staff person. Citations are issued on the attached LIC809D pages.