Non-compliance follow-up·January 5, 2026

Unannounced case management visit conducted on 01/05/2026 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Janet Jones. A brief interview was conducted with the facility designated Administrator at this time. Current census was 41 residents. The purpose of this case management visit was to follow up, with quarterly visits, and inquire about the requirements that were laid out from the office meeting for the non compliance conference which took place back on 03/04/2024. The following items were required to be maintained in compliance while this facility was under increased monitoring with quarterly visits: Maintain adequate facility staffing Uphold all Personal Rights of the Residents Maintain and conduct Personal Rights training and verification for new and existing employees Facility designated Administrator must maintain oversight of facility staff for proper care and supervision Make sure that this facility is following all Reporting Requirements Updating policies and procedures for resident fall risks Make sure that facility staff are always seeking timely medical attention Update and maintain Needs/Appraisal Training for all staff Maintain and train all care staff on proper documentation for the facility Communication Log This LPA was also present today to follow up on several incident reports that were recently submitted for the following residents in care: R1 R2 R3 There were no deficiencies observed or cited during today's case management visit. Exit Interview