Non-compliance follow-up·February 22, 2022

02/22/2022 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director Sue Todd. The purpose of this visit was to discuss staffing schedules pertaining to a recent non-compliance meeting. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves. The facility has been reporting weekly staffing schedules to LPA Knight since the end of December 2021. Review of these weekly staffing schedules showed no significant staffing issues. Ms. Todd stated When we started the reporting phase we had 42 employees. We ran an ad for on call staff and over time back filled our full time openings. We are still implementing 2 med techs for the day and evening shifts. The night shift has 1 med tech, but we have 1 additional staff that comes in at 4:00 AM for a total of three staff for that shift, which is when the residents start waking up and may require more assistance. We hired 1 staff from a staffing agency to cover 4 shifts because we were Covid positive and down staff for the evening shift. This allowed us to give our staff a break from working additional overtime. We have not had any incidents of concern. No deficiencies were cited as a result of today's visit.