Non-compliance follow-up·March 26, 2024

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 3/26/24 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. LPA met with the Executive Director, Tracy Lehner. During today's visit, LPA reviewed the following stipulations of the order: 1. Staff shall have criminal record clearance -LPA checked criminal record clearance for all staff 2. Staff have current CPR training certification -LPA observed current CPR certifications for staff 3. All medications and toxins shall be locked away and inaccessible to residents -LPA observed all medications and toxins to be locked away 4. Facility shall be clean, safe, and sanitary -LPA toured facility which was clean, safe, and sanitary 5. Facility shall conduct monthly quality assurance audits for 1 year -LPA observed monthly quality assurance audit reports LPA 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.