complaint·October 28, 2021

During the course of the investigation LPA interviewed 1 administrator, 1 maintenance staff, and 4 care staff. LPA obtained the following documents to investigate the above allegations: Facility Food Handling & Safety policy, Medication Handling Policy, Visitor policy, pest control invoices, receipt for repair supplies, staff list with contact information. Allegation: Staff do not wear masks or gloves. - UNSUBSTANTIATED. During LPA Knight’s visit to the facility on 7/12/2021 to conduct an Infection Control Annual Inspection LPA observed all staff who were in the facility wearing face masks. Staff are not required to wear gloves at all times in the facility. Staff interviews revealed that all staff are aware that they are required to wear masks at all times while they are in the facility. Staff confirmed that they are all wearing masks while they are inside of the facility at all times. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated Allegation: Facility has pests. - UNSUBSTANTIATED. Review of invoices from T. Brooks Pest Control revealed that the facility has regular pest control service and additional bed bug service treatments. Administrator stated the facility covered all of the mattresses with bed bug protectors. The pest control company comes in twice a month and treats the affected rooms, and staff goes through the facility every week with housekeeping to inspect for bedbugs. Staff interviews confirmed that the facility does have an issue with bed bugs, and that the facility has regular pest control services. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated Continued on LIC9099C Allegation: Facility staff does not handle residents' medications and food in a sanitary manner. - UNSUBSTANTIATED. Review of the facility’s Food Handling & Safety policy revealed that the facility trains staff to wash their hands with warm soap and water for 20 seconds and to follow the “no bare hands” rule which teaches that an individual’s bare skin should not come into contact with ready-to-eat foods. Instead, alternative procedures should be practiced, such as using tongs, spatulas, deli tissue, or wearing clean, single-use gloves. It was learned during staff interviews that all staff sanitize their hands and wear gloves before preparing or serving food. Review of the facility’s Medication Handling Instructions revealed that staff are trained to first wash their hands for at least 20 seconds at the start of a medication pass and wear sanitary gloves although wearing gloves is not required by CCLD regulations. CCLD requirements do not include the use of gloves when handling medications, the requirement is to ensure the area where staff handle medications is clean and sanitary. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated An exit interview was conducted. A copy of the report was emailed to facility administrator Micah Carey. No deficiencies were cited on today’s date.