| 340:110-3-153.1(g)(1) | References. The program obtains three references for personnel prior to employment. Copies are maintained in the employee's personnel record. | 6 personnel did not have documentation of references being completed prior to hire. | References will be completed prior to hire. | 03/12/2026 | No |
| 340:110-3-153.1(g)(3) | Performance evaluation. A written performance evaluation is updated at least annually and maintained in the employee's personnel record. | There was no documentation of 4 personnel receiving performance evaluations being completed for 2025. | Performance evaluations will be completed annually | 03/12/2026 | No |
| 340:110-3-153.1(l) | Orientation. Personnel receive orientation after employment date and within 30-calendar days of employment. | 10 personnel did not have documentation of completed orientation. | Orientation will be completed within 30 days of employment | 03/12/2026 | No |
| 340:110-3-153.1(m) | Personnel professional development. Professional development the program schedules is obtained on or after personnel's employment date. Personnel meet professional development requirements in (1) through (7) of this subsection | 13 personnel did not meet professional development requirements. | Personnel will meet professional development requirements | 03/12/2026 | No |
| 340:110-3-153.1(o)(2)(A) | an OKDHS-provided personnel information sheet, completed for each personnel upon employment and submitted to Licensing within two weeks of his or her employment; | Licensing did not receive 2 personnel information sheets within 2 weeks of employment. | Personnel information sheets will be submitted to licensing within 2 weeks of employment. | 03/12/2026 | No |
| 340:110-3-154(a)(6) | Residents receive a medical examination by a licensed health care professional within 60-calendar days prior to admission or within 30-calendar days following admission. However, a documented medical exam performed within the 12 months prior to admission is acceptable when a resident is transferred from another licensed program. | 2 residents did not have medical exams completed timely. | Medical exams will competed timely | 03/12/2026 | No |
| 340:110-3-157(h) | Bathrooms. Bathrooms are maintained in a clean and sanitary condition with adequate ventilation. | The toilet in room C was leaking. | Service has been contacted for repair. | 03/13/2026 | No |