Non-compliance follow-up·February 22, 2024

On 2/22/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an unannounced quarterly on-site visit regarding the Stipulation and Waiver and Order adopted on 05/23/2022. LPA met with Vicky Cross, Administrator, and explained the purpose of the visit. During today's visit, LPA was provided the Compliance Binder, and observed a copy of the Stipulation in the binder. LPA observed weekly calls conducted with consultant group to discuss medication room operation. LPA observed in-service education of Care Plan Review conducted on 2/1/2024 with shift manager and caregivers. LPA observed documentation of monthly staff training, Dementia training conducted on 1/17/2024 and Confidentiality/HIPPA training conducted on 2/20/2024. LPA observed quarterly audit from consultant group last serviced on 11/13/2023. LPA was informed next audit is currently being conducted date of visit and the day after. LPA observed documentation of Licensees quarterly on-site visits ensuring quality control conducted on 12/5/2023 by Solar Senior Living and on 12/9/2023 by Ciminocare. At this time, LPA found facility to be in compliance with the Stipulations and Waiver; And Order. No deficiencies observed. Exit interview conducted and a copy of report will be provided to Administrator via email.