Routine inspection·August 22, 2025

Licensing Program Manger (LPM) Liza King and Licensing Program Analysts (LPA) Noel Wolf Petersen arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPm was met by Executive Ast and administrator joined 30 minutes later. LPM explained the purpose of the visit to Administrator and Executive Ast. Facility currently has 6 residents receiving home health, 7 residents on hospice, 5 residents use a hoyer lift. Staffing on average is Am shift 2 MedTechs(MT) and 7 caregivers (CG) PM shift 5 CG and 1 MT and overnight shift 3CG and 1MT. LPM and Executive Ast inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Throughout the day LPM and LPA observed breakfast and lunch service, exercise program, neighborhood walking groups, bingo and painting and fresh popcorn service. Chemicals and medications noted to be locked to residents in care. Residents rooms did contain various personal care products and cleaning supplies which could pose a risk to those clients that wander throughout the facility. No bodies of water were observed at the facility. cont. Hot water temperature was measured at 107 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPM observed the all necessary posters on the facility wall: incl but not limited to Facility license, See Something Say Something poster, Ombudsman poster, Rights of Resident/Family Councils. LPM reviewed 7 resident files (3 of which were on hospice) all medical assessments and care plans appear to be up to date. Additional documentation reviewed included Hospice documentation and daily notes, Centrally Stored medications lists, MARS, and admissions required documents. R6 during the month of July 2025 went without a medication for heart failure for 3 consecutive days and during Aug 2025 the resident went without the same medication for 8 consecutive days and counting. A discussion occured and an explanation was provided that the medication is not covered by the resdients current medical provider, no alternative means have been identified. A Citation will be issued. The facility has recently changed to a new EHR system. LPM toured the facility during breakfast service and again in the afternoon to observe repairs that have been made. During the morning tour, LPM observed: A tour of the kitchen revealed unlabeled foods in the Refrigerator , freez er and pantry. The seal on the door of the freezer was not working properly causing food to be freezer burned and damaged. Additionally a flickering light was obsereved in the hall, multiple screens had holes and the elevator was broken. A repeat tour was conducted and all items were repaired except the flickering light on the hall and screens, technical assistance provided. A citation was issued during todays annual inspoection related to medication administration, an exit interview was conducted with Kasey Wimmer and Appeal rights were provided.