complaint·January 15, 2025

(Continued from LIC9099 p.1) Staff informed that the facility's required infection control protocols were put in place, including Personal Protective Equipment (PPE) carts placed outside of the affected residents' rooms, full PPE donned by staff assisting the affected residents, CDC signs placed on the affected residents' doors, notifications made to the affected residents' responsible parties and physicians, and Public Health notified. Interviews with staff revealed consistent knowledge of facility protocols regarding infection control procedures at the facility. The information provided by staff regarding the infection control protocols that were in place were corroborated by facility records. The facility's Illness Tracking Form during the timeframe of complaint showed that five (5) Covid-19 cases existed at the facility. The tracking showed that at most, two (2) residents were under isolation protocols concurrently. Narrative Charting Notes for the residents in question during the timeframe of complaint corroborated staff statements that the physicians and responsible parties for the residents in question were notified of the positive COVID-19 test results. The infection control process outlined by staff was corroborated by the facility's Infection Control Plan, dated 07/01/2023. The Infection Control Plan was absent of directives regarding when the community should be notified of positive Covid-19 cases. Outside source interview with the facility's infection control trainer revealed that the recommendation was for communities to be notified of COVID-19 when the facility reached outbreak status, which was three (3) or more cases occurring at the same time. The outside source did not express concern regarding the facility's adherence to Covid-19 protocols and regulations. Staff statements regarding contacting Public Health were corroborated through website tracking verification with date and timestamps. LPA directly observed the facility's infection protocol specific to COVID-19. LPA observed the use of PPE, disinfectant and sanitation practices, and CDC signage. The observations made by LPA were consistent with staff interviews, outside source interviews, and records review. The investigation did not produce evidence that the Licensee did not follow their infection control notification policy. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.