Routine inspection·May 25, 2021

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and met with Administrator, Wendy Watson. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA observed that facility has hand sanitizer outside of the entrance to the facility and once inside the facility, the receptionist checked LPA's temperature and asked standard Covid-19 Screening questions. Visitor log is completed by the receptionist. LPA conducted a walk-through of the facility with the Administrator and observed Covid-19 posters throughout the facility that included hand-washing signs in each public bathroom. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was observed throughout the facility and outside of each resident's room. Per Administrator, they regularly discuss infection control with residents and staff. Residents are encouraged to wear masks when outside of their rooms and staff are required to wear them while in the facility. Observed staff had masks on during this visit. Facility is allowing for 25% of residents to dine at a time and dining furniture is set up for social distancing. Some residents prefer to eat in their rooms and that is being accommodated. Common areas are also set up for social distancing. LPA and Administrator discussed resident activities and visitation. Facility staff have completed PPE training and have been N-95 Fit tested. Administrator showed LPA documentation of training and disinfection. Commonly touched surfaces are disinfected three times per day and logged. Dining room table and chairs are disinfected between residents. Public bathrooms and employee break rooms are disinfected after use. Facility has submitted and received approval for their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, face shields, gowns and hand sanitizer. LPA confirmed that Administrator has reviewed PINs 21-17-ASC and 21-17.1-ASC for new guidance regarding visitation, communal dining, ect. Administrator and LPA discussed their Emergency Disaster Plan No deficiencies cited during this inspection.