Routine inspection·May 13, 2022

Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by S1, and met with Licensee Annie Jane Mikenas who was informed of the purpose of the visit. At the time of visit there was 3 staff and 5 residents present. The facility currently has zero positive or suspected Covid-19 cases. During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings at the facility. A single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. LPA advised Licensee to document temperatures for staff, visitor and residents. This will be documented on an LIC9102TA. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all restrooms. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA observed a sufficient 30-day supply of PPE equipment. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces. LPA was provided with a copy of the facility Mitigation plan and Licensee will submit this to the department by 5/16/2022 5:00pm. During the tour of the facility LPA and Licensee observed the following deficiencies: · LPA requested a current resident roster LIC9020. The facility did not have a resident roster. LPA was given a typed up list of residents that was outdated with 2 residents (R1 and R2) that had expired. LPA also noticed R3 who had passed away “a couple weeks ago” per S1 was not on the typed sheet. · LPA observed PRN medication in the refrigerator that was not locked in the designated lock box. · LPA reviewed SIR log and noticed the last SIR was dated in 2017. LPA inquired with Licensee about SIR’s including death reports for R1, R2 and R3. Licensee was able to show proof of SIR's submitted for R2 and R3 but not for R1 who had expired more than 7 days ago. · LPA observed observed S2 and S3 on LIC500 who were not associated to the facility. S2 is cleared but not associated and worked at the facility per Licensee. This a zero tolerance related regulation. Licensee will receive a civil penalty of $500. S2 does not posses a background clearance and is listed as a staff member on LIC500. For this Licensee will be issued a civil penalty of $500. Civil penalties will total $1000. An exit interview was conducted, a copy of this report, and appeal rights were provided to facility licensee, Annie Jane Mekinas.