Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Licensee, Martha Lovejoy. The inspection is focused on the Infection Control procedures and practices of this facility.

LPA initiated a walk-through of the facility around 12:00pm and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had a mask on during this visit. Commonly touched surfaces are disinfected once per day in the morning. Facility maintains documentation of staff and resident daily temperatures. LPA was not screened upon entry but did confirm that Licensee had a thermometer and a sign in log for visitors. LPA reminded Licensee that all visitors need to be screened upon entry but facility no longer needs to verify vaccination of visitors per recent guidance.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment (PPE) but have not been N95 fit tested. Licensee and LPA discussed visitation and activities.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced December 2021. Smoke and carbon monoxide detectors throughout facility were tested and operational.