Routine inspection·November 17, 2023

At 9:50am on 11/17/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct the annual inspection. LPA signed in at the front desk and had Maintenance Staff (S1) contact the Administrator. Administrator Kirk Klotthor arrived at 10:10am, LPA announced who he is and the reason for the visit. This facility has 64 bedrooms/bathroom suites, currently the rooms occupied are all single occupancy at this time. This facility is 3 stories, the first floor there is a large waiting and entrance way with front desk. There is an enclosed center courtyard, there is a kitchen and dining room, resident rooms, mail room, storage rooms and facility offices. The second floor has a beauty salon, storage rooms, central medication room, activities room and resident suites. The 3rd floor has resident rooms, locked storage closets, and an activities/library room. The grounds also have independent living facilities located next door and plenty of outside seating and walking ways for residents. There is a designated smoking area in the back parking lot of the grounds. Administrator and LPA conducted a tour of the facility, LPA observed, all floors, kitchen, dining room, all activities rooms, medication room and a sample of residents rooms. LPA noted that there are fire extinguishers placed throughout the facility all in the green and currently tagged for service. LPA noted that the facilities walkways and exits, were free and clear of debris and obstruction. LPA noted that Alpha Fire conducted a comprehensive 5 year evaluation of the facilities sprinkler system on 11/14/2023 with no issues. LPA noted that the food supply met regulations for 2 days of perishables and 7 days of non-perishables for more than 51 residents. LPA noted that there were no special diets. LPA conducted a sample medication audit and reviewed Centrally Stored Medication Records and found no issues. LPA reviewed sample staff files and found no issues. LPA reviewed sample amount of resident fils and found no issues. LPA conducted full care tools review. LPA noted one technical violation, of liability insurance pertaining to amount of aggregate, Administrator will address before 12/01/2023. No other violations, or citations were discovered during this annual inspection. Exit interview, report read, and report provided.