Routine inspection·October 17, 2024

On 10/17/2024, Licensing Program Analysts (LPA's) Tobola & Jain conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Executive Director, Mark Nitcsche & Healthcare Administrator, Ryan Banner. The facility currently provides care for 298 residents, 1 of which is receiving hospice services, along with a designated memory care unit. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located on each resident floor and kitchen were found to be last charged on 1/25/2024. Smoke and carbon monoxide detectors were interconnected and found throughout the facility. Fire Safety Inspection is completed on a monthly basis with all fire safety devices and systems to be in order. Water at faucets accessible to residents measured between 105.4 and 108.5 degrees F which is within regulation. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished constantly through the week and stored properly. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. Cleaning supplies and other toxins are safely stored in locked closets throughout each floor, and housekeeping/maintenance rooms all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. Residents that were awake during the inspection were observed interacting with staff, fellow residents and visitors in the common areas, or in their bedrooms resting. The facility encourages regular family visits and utilizes a wide variety of activities with LPA observing staff engaging continuously with residents, offering activities based on individualized preferences. LPA found that staff and resident engagement is well practiced with activity calendars developed on a monthly basis. Residents were observed to have a positive and personable relationship with staff and Executive Director. There are multiple outdoor patios for resident use, all equipped with appropriate shading. Continued onto LIC809-C LPA conducted a sample file review for five (5) residents and found that resident (R1) physician's report is in need of updating. Technical Violation issued. Upon a spot check of five (5) staff files, LPA found that caregiver staff have annual training completed. However, 2 out of 5 staff reviewed are in need of updated 1st aid certification. Technical Violation issued. Lastly, a spot check of medication was conducted in the assisted living unit and found that all medication counts and records are in order. Upon spot check of medications in the memory care unit, LPA's found several medications in need of reconciled start dates and input. Technical Violation issued. Ryan Banner's Administrator Certificate 7026388740 is currently active through 10/05/2025. LPA requested the following documents be sent to CCL by COB 10/31/2024: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan Liability Insurance