Routine inspection·October 29, 2025

On 10/29/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required annual inspection and was greeted by a staff member. The LPA identified herself, explained the purpose of the visit, and asked to meet with the Administrator. The Health and Wellness Director/acting Administrator Kurtis Woody was on-site (Administrator Certificate #6073581740, expiration date 01/03/2026), and an interview followed. The Administrator accompanied the LPA on a tour of the interior and exterior of the physical plant. The CARE inspection tool was used during this inspection. The facility includes Assisted Living, Memory Care, and Independent Living units. The licensed one-story Memory Care unit is located across a paved walkway from the two-story Assisted Living unit. The facility is licensed for a capacity of 114 residents, including 23 ambulatory and 77 non-ambulatory, of which 14 can be bedridden. It had a hospice waiver for 7. At the time of the site visit, the census was 77 residents, including 24 in Memory Care and 53 in Assisted Living. The LPA inspected the physical plant, including but not limited to the dining areas, kitchens, storage rooms, activity rooms, common areas, resident bedrooms and bathrooms, laundry rooms, and outside patios to ensure compliance with Title 22 regulations. The Facility License, Complaint Hotline Poster, Ombudsman information, menus, and activity calendars were publicly posted. The LPA toured the kitchen and interviewed the Kitchen Manager. The entire kitchen, including its appliances, working surfaces, floor, and storage areas were clean, sanitary, and odor-free. The LPA observed a two-day supply of perishable food and seven-day supply of non-perishable food, located in upright freezers and refrigerators, storage rooms, and a walk-in refrigerator/freezer. Food was properly stored, and safe food storage guidelines were prominently displayed on the wall. Daily cleaning schedules for the AM and PM shifts were posted. Refrigerator/freezer temperature logs and food temperature logs were posted in visible locations and actively used daily. Appliances were in working order. The stove hood was clean and last serviced by IC Refrigeration in June 2025. The LPA observed lunch service. Food portions were adequate, and the meal contained a variety of food types. Daily menus were located on each table. The LPA observed residents eating and socializing. The LPA toured common areas intended for resident use, including hallways, theater, game room, gym, and bistro. These areas were decorated, clean and odor-free. They had adequate furnishings and lighting in good repair and working order. The thermostat was set at 76 degrees Fahrenheit. There was an evacuation chair at the top of each staircase and evacuation maps posted throughout the facility. The elevator was last inspected on 3/6/2025. The facility had an Ansul fire suppression system that included sprinklers and pull alarms; it was last serviced by Imfeld Cloutier Fire Protection on 7/28/2025. The fire extinguishers were last serviced by the same company on 7/23/2025. Chemicals were properly stored in locked housekeeping storage rooms. There were smoke and carbon monoxide detectors in working order in resident rooms and hallways. In the Memory Care unit, the LPA exited the building through a side door. The alarm sounded immediately and a staff responded to the alarm within a minute. The LPA observed ten residents’ living quarters. The resident apartments were clean and odor-free. Apartment units contained the required furnishings, and each was personalized with residents’ own belongings. The windows were in good repair and there were large closets for storage. The bathrooms contained working water fixtures, sturdy grab bars, and non-slip flooring. The LPA measured the temperature of the hot water in two resident bathroom sinks. The hot water was 108 degrees Fahrenheit, which was within the required regulation of 105 to 120 degrees Fahrenheit. While in a resident room, the LPA pushed the call button. Staff responded within three minutes. The LPA toured the outside areas. Walkways were flat, smooth, and free from obstruction. The grounds were manicured and decoratively planted. Interior courtyards in both the Memory Care and Assisted Living units contained seating and shaded areas for residents. Due to time constraints this required 1 year annual will be continued at a later date. An exit interview was conducted with the Memory Care Director and a copy of this report was provided.