Routine inspection·December 3, 2021

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee/Administrator, Arlinda Gregorio. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA was screened for Covid-19 symptoms which includes having temperature checked and filling out questionnaire with standard Covid-19 screening questions. LPA initiated a walk-through of the facility around 9:25 am and observed the following: Facility has COVID-19 posters throughout that includes hand washing signs in bathroom. Hand sanitizer is located throughout common areas of the facility and in resident rooms. Other hand-washing supplies were also observed in bathrooms. LPA confirmed with Licensee that they are conducting vaccine verification for visitors per Provider Information Notice (PIN) 21-40-ASC. Facility was a comfortable temperature and exits were free from obstructions. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected at least twice per day, and after use. Facility maintains documentation of staff and resident daily temperatures. LPA confirmed that facility is following the staff vaccination guidance per PIN 21-44-ASC. Licensee has been requested to review PIN 21-49-ASC regarding updated guidance on communal dining, group activities, entertainment, non-essential services, and transportation. Facility has a designated visitation area outside and is allowing for inside visitation after vaccination verification or proof of a negative test within 72 hours, per current CCL guidance. Visitors are required to wear a mask while in the facility. Staff have completed PPE training but have not been N95 fit tested. LPA and Licensee discussed options for having staff fit tested. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns and hand sanitizer. Facility maintains a 30 day supply of medication. Licensee and LPA discussed their Emergency Disaster Plan. Fire extinguishers were last serviced July 2021. Smoke alarms throughout the facility and Carbon Monoxide detector were tested and operational. No deficiencies cited during this inspection.