Non-compliance follow-up·April 21, 2022

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management visit regarding the facility's current probationary license. LPA met with facility administrators Brisa Romero (Admin 1) and Gary Sneper (Admin 2). LPA toured the facility with Admin 1. During tour of the facility, LPA observed the facility to be operating within regulation, including compliance with personal rights and allowable health conditions. LPA observed the facility's probationary license posted both on the bulletin board outside of the Administrators office, as well as framed in the receptionist's office. LPA confirmed maintenance of home health agreements. Admin identified licensed vocational nurse Melissa Bray (LVN) the facility's Infection Prevention (IP) specialist. LPA observed RN working at the facility during the inspection. In interview with LVN, LVN stated that they had been working at the facility since February. LPA reviewed LVN's IP training certificates. Records indicated that between the days of 02/11/2022 and 02/15/2022, RN completed 17 courses related to infection prevention. LPA confirmed completion of staff training on infection prevention. During the inspection, LPA requested administrator training documentation. During records review, LPA observed that from the dates of 02/03/2022 to 03/15/2022, Admin 2 completed 42 hours of training. Facility request to lift probationary period is currently under review No deficiencies cited during today's visit. This report was reviewed with facility administrator Brisa Romero and a copy of this report was provided.