Administrator did not submit the new infection control plan to LPA. Administrator reported to LPA she did not receive the notification to submit one. LPA sent a copy of the LIC9282 and requested to Administrator to have it completed and submitted to LPA by the end of the week. Physical plant inspection was conducted with the Administrator. The facility has (4) bedrooms; with (2) shared and (2) private. All bedrooms were properly furnished. The common areas were observed to be clean, including bathrooms, with soap and towels, and hand washing signs visually posted. Facility cleans everyday, especially in common areas. Meals are individually served in resident's rooms.

The Administrator reported to LPA, the facility has documentation of all vaccination records and other pertinent information pertaining to COVID-19, in staff and resident files. Administrator has declined to accept new residents, unless there is proof of vaccination. Administrators reported to reading the departmental emails. Facility has in-house COVID test kits and conducts testing as needed. Residents temperature is taken daily and recorded. Administrator has sufficient staff at this time; new hires must be fully vaccinated before employment. There is no sick leave policy at this time.

LPA conducted a file review for staff and residents, to ensure documentation is current and valid. Training and CPR/First Aide, were current and valid. Resident files were reviewed with current information. There were no issues observed during today's visit.

Exit interview was conducted with Administrator.