Routine inspection·February 4, 2022

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee, Teresita Shevick. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA observed that facility has a sign in sheet for visitors and their temperature is documented. LPA conducted a walk-through of the facility and observed that all exits were free from obstructions. Covid-19 posters were posted throughout the facility that included hand-washing signs in each bathroom. Hand sanitizer was observed in common areas and are located in resident rooms. Facility has PPE stations outside of isolation rooms. Facility staff have completed PPE training and have been N-95 Fit tested. Facility screens residents once a day and staff daily for Covid-19 symptoms and results are documented. LPA confirmed that facility is following the staff vaccination guidance per PIN 21-44-ASC. Residents are encouraged to wear masks while in the community and staff are required to wear masks while in the facility. All staff had masks on during this visit. Facility disinfects commonly touched services daily and after each use. Facility has a designated visitation area outside and is following current visitation guidelines. Facility has submitted a Covid Mitigation Plan that has been reviewed by CCL. LPA observed at least 30 days of PPE including gloves, face shields, masks and gowns. LPA and Licensee discussed facility's Emergency Disaster Plan. Fire extinguisher was charged but has not been serviced within the last year. Due to residents in isolation, LPA was unable to test smoke alarms but Licensee agrees to have fire system checked. No deficiencies cited during this inspection.