Routine inspection·April 9, 2026

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Karen Nickolai. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room. LPA randomly toured the following but not limited to bedrooms: residents bedrooms on both the first and second floor: 201, 203, 229, 231, 233, 235, 238, 236, 211, 213, 215, 216, 220, 219, 226, 209, 207, 232, 234, 107, 109, 111, 113, 115, 114, 117, 119, 120, 104, 101. There was no obstruction to block the walkways. The staff area of the facility was also inspected. LPA tested the delayed egresses in the facility. When tested the delayed egresses emitted a loud sound, which continued to ring until staff reset the alarm. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 114 degrees F in resident bathrooms. Fire extinguisher was serviced in April 16, 2025. The facility was equipped with smoke and carbon monoxide detectors. The Facility's Sprinkler System was last inspected on March 27, 2026. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on March 27, 2026. LPA reviewed facility disaster plan, which was last reviewed/updated on April 9, 2026. During todays visit, LPA requested a copy of the following residents death certificates (DR1-DR4). LPA also requested information regarding DR2-DR4's diagnosis. LPA reviewed facility records for 4 staff and 4 residents. LPA reviewed 4 resident medications and centrally stored medication records. LPA noted during medication audit/Review, that residents R1, R2 and R3 had medications that were not listed on the centrally stored medication record. Resident R1 did not have his/her medication M1 (fill date March 5, 2026) listed on his/her centrally stored medication record. Resident R2 did not have the following medications listed on his/her centrally stored medication record: M2 (fill date 3/4/2026), M3 (Fill date 11/11/2025), M4 (Fill date 12/24/2025), M5 (Fill date 12/24/2025). Resident R3 did not have the following medications listed on his/her centrally stored medication record: M6 (Expiration date October 2026), M7 (fill date 12/31/2025), M8 (Fill date 12/31/2025), M9 (fill date 3/28/2026) , M10 (Fill date 12/12/2025), & M11 (Fill date October 3, 2025). LPA showed the discrepancies to the health services director Kyleigh Whitely. No documentation was provided by health services director Kyleigh Whitely to LPA, to verify that the medications in question were included in each corresponding centrally stored medication record. A deficiency and technical violations are being cited during today's visit. This report was reviewed with Administrator Karen Nickolai and a copy of the signed report was provided. Appeal Rights were provided.