Routine inspection·January 30, 2023

Licensing Program Analyst, Amber Coleman arrived at the Excel Care Facility unannounced to conduct an Annual Inspection with a focus on infection control. LPA introduced self and stated the purpose of the visit. LPA met with Dorris Anderson, Administrator. LPA signed in at the facility's COVID station. At the COVID station, LPA observed hand hygiene, PPE and signs for infection control posted. LPA was provided a space to work before completing walk through of facility. Administrator reports at this time there are no residents or staff suspected of COVID symptoms. LPA observed serval staff members also wearing proper PPE. Current census is 10. During the inspection, LPA interviewed Administrator pertaining to the facility's infection control measures and other health and safety concerns. LPA observed necessary signs posted in the facility, including signs related to COVID-19, which were in accordance with the Department's guidelines. Administrator stated that the facility is equipped with sufficient PPE, hand hygiene supplies, and sufficient cleaning/disinfecting provisions. Extra supplies were observed in the secured facility laundry room. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation of residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms. ***Please See LIC809C*** At approximately 2:30pm LPA observed room #6. Room #6 is currently occupied by 1 resident. LPA observed the resident lying on the bed. The bed consisted of 2 twin sized box springs and 2 twin sized mattresses stacked on top of one another. Administrator explained that resident #1 is at risk for falls due to a medical/behavioral condition. The bedframe and headboard were removed to prevent injury. At approximately 2:40pm, LPA completed walk through of the kitchen area to make view of the facility's food supply. LPA observed 5 cans, of 5 cans 4 cans had expired. Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, deficiencies issued. A exit interview was conducted and a copy of this report LIC809C, LIC809D, appeal rights were provided to Administrator Dorris Anderson.