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25 | At approximately 9:20 AM on 02/15/22, 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 disclosed the reason for the visit.
Census: 5
Entry: The front yard was maintained and surrounded by an unlocked gate. A ramp led to the facility’s entrance. A sign regarding the facility’s vaccination and masking requirement hung on the front door. The facility had one main entrance designated for screening visitors, staff, and residents. Inside, LPA observed signs for Droplet Precautions, cleaning procedures, handwashing technique, confidential complaints, personal rights of residents, and ombudsman information.
Screening: Upon entry, LPA was screened by staff. LPA recorded temperature, symptoms, and contact tracing information in a visitor log. LPA observed a screening station which contained a digital thermometer, symptom questionnaire sheets, surgical masks, N95 masks, face shields, sanitizer, gloves, and rapid test kits.
At approximately 9:30 AM, LPA conducted a physical plant tour.
Safety: LPA observed Emergency Evacuation Plans with routes clearly labeled in all bedrooms and at the front entrance. All smoke detectors were functioning. Water temperatures tested in Bathroom #1 at 105.5 degrees Fahrenheit. Emergency exits paths were clear and unlocked.
Bedrooms: The facility had 5 bedrooms. One bedroom is designated for staff. The staff bedroom was locked and contained no hazardous items. Two resident bedrooms, Bedroom #2 and Bedroom #4 are shared. Resident beds were at least 6 feet apart to accommodate social distancing. Two resident bedrooms, Bedroom #1 and Bedroom #3 are private. All bedrooms contained adequate storage space, clean linens, televisions, nightstands, and lamps. Bedroom#1, Bedroom #2, and Bedroom #3 had exit doors in the room with ramps leading out.
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