Non-compliance follow-up·August 23, 2023

Licensing Program Analysts (LPAs) Angela Hood and Jaynae Boyles arrived at the facility unannounced on 8/23/2023 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 3/28/2023-3/28/2025. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review upon request. LPAs met with the Executive Director, Tracy Lehner. During today's visit, LPAs reviewed the following stipulations of the order: 1. Staff shall have criminal record clearance -LPAs checked criminal record clearance for all staff 2. Staff have current CPR training certification -LPAs observed current CPR certifications for staff 3. All medications and toxins shall be locked away and inaccessible to residents -LPAs observed all medications and toxins to be locked away 4. Facility shall be clean, safe, and sanitary -LPAs toured facility which was clean, safe, and sanitary 5. Facility shall conduct monthly quality assurance audits for 1 year -LPAs observed monthly quality assurance audit reports LPAs observed facility to be in compliance and residents receiving care. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.