Routine inspection·August 3, 2022

On 08/3/22 at 9:15 AM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon entry into facility, LPA explained the purpose of the visit. LPA met with and toured the facility with Licensee Donald Hay. Facility has a Covid-19 mitigation plan in place. However, they are not following many aspects of it, including front door signage nor requesting Covid-19 vaccination of visitors. Further, they have not added an infection control plan to their plan of operations as PIN 22-13-ASC - Adult And Senior Care (ASC)- Updated Regulations For Infection Control Requirements requires that they do. The designated infection control leader is the Licensee. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log and a no touch thermometer, hand sanitizer, and face masks. Inside of the facility, some COVID-19 signs were posted to promote hand washing, cough/sneeze etiquette and physical distancing. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. Carbon monoxide and smoke detectors were fully functional and the fire extinguisher had been serviced within one (1) year and it was fully charged. A written Emergency/Disaster plan was posted. Centrally stored medications were in locked cabinets, and sharp objects were stored in locked closets and cabinets. The temperature inside of the facility was 77.4 and the hot water was 105 degrees Fahrenheit, both of which were in the safe range. An administrator is on site more than the required 20 hour minimum each week to oversee business operations. Facility cited with 1 Type A and 2 Type B deficiencies: Continues on LIC 809-C . . . . . . Continued from LIC 809 Physical Plant/Environmental Safety - Type A: 87309(a)(1) - Kitchen cabinets with poisonous cleaning and repair supplies were unlocked. The contents of those cabinets included cooking fuel, mineral spirits, Raid, and cleaning supplies.I nfection Control Practices - Type B: 87464(f)(1) - No signs were posted at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect residents from infection during pandemic, which was not in accordance with personal rights requirements. Physical Plant/Environmental Safety - Type B: 87303(i)(1)(B) - Auditory signal device at back door broken. Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 08/10/22: · LIC500 - Personnel Report · LIC308 - Designation of Facility Responsibility · LIC610E - Emergency/Disaster Plan · Evidence of Liability Insurance & Surety Bond A total of 3 deficiencies cited during this visit. Exit interview conducted and a copy of this report provided via email.