Routine inspection·February 24, 2022

Licensing Program Analyst's (LPA's) Olson and De Leon conducted an on-site 1 year infection control annual visit to the facility above on 02/24/2022 at 9:50 AM. LPA's met with Administrator Cheryl Marsh and explained the purpose of the visit. LPA took a physical plant tour of the facility with staff. The facility has submitted a mitigation plan to the department, and it has been approved. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening on all staff and visitors wanting to come into the facility. All documentation is kept in a file. The entry station has hand sanitizer along with a thermometer. The facility has multiple areas spaced to accommodate as much space as possible for social distancing. The facility has a large courtyard for resident use with a couple umbrellas. All equipm ent and PPE supplies are kept in the storage closet. Medications are kept in a locked medication room. The staff screen residents for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. Signs are posted on the front door, entry area regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Continued 809-C Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Health and Wellness Director is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other negative individuals until cleared by Health Department to do so. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has single rooms with restrooms and they are disinfected bi-weekly or daily in Memory Care. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room. The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked office. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Administrator Certificates are valid. Fire extinguishers were charged and inspected annually. The facility has hardwired smoke and carbon monoxide detectors thorough the facility. Continued on 809-C At around 10:35 AM LPAs noticed the Memory Care common area had an accordion door that was open. There is a sign that says “Staff Only” but the area was not locked and LPA Olson noticed cleaning products, lotion, staff food, coffee, and a Monster drink. These items were unlocked and easily accessible to any Memory Care resident. At 10:40 LPA Olson saw an unlocked door to a staff restroom. Staff on tour immediately closed door which then locked. LPA Olson asked to see the inside of the restroom. LPA Olson observed full bottles of Acrylic Paint in the unlocked cabinet. At 10:50 AM LPA Olson observed pallets, holes, and materials out in the Courtyard that should not be there and needs to be repaired. At 11:00 AM LPAs observed stairwell by door 7 did not have an emergency evacuation chair. Administrator stated paining was done and it was lost in the process. A new one will be ordered today 2/24/22. Exit interview completed, deficiencies cited, civil penalty issued, copy of report and appeal rights emailed to Administrator/Licensee.