Office review·March 4, 2024

A Noncompliance Conference (NCC) was conducted today on 03/01/2024, via Microsoft Teams. The purpose of the NCC was to discuss the Substantiated complaint of a violation of personal rights. Present at today’s NCC were the Regional Office Manager Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Charlie Yang, and facility designated Administrator, Jose Ventura, Kathy Lazernik (Facility Nurse), Cindy Scheublein (Executive Director) . The administrative process was explained during this meeting and the facility designated Administrator was informed that further citations may result in Administrative Action. The focus of the concerns at this time: Facility staffing Personal Rights of the Residents Personal Rights training and verification Maintaining continued compliance Oversight of facility staff for proper care and supervision Reporting Requirements Updating policies and procedures for resident fall risks This facility and the facility designated Administrator agreed to the following: Complete and submit the LIC 500 for the most current staff, shifts, and coverage for designated shift leads Complete and submit the LIC 308 Complete and submit the LIC 309, as well as, the most updated documents from the Secretary of State filing for this corporation Complete and submit proof of most recent training in the areas of Resident Personal Rights, Resident Care, and Resident Supervision. Proof of submission to include name of trainer, topics covered with duration of training, and list of all attendees Complete and submit proof of most recent training for proper completion of the LIC 624 for all staff by 03/11/2024 Complete and submit proof of most recent training for fall prevention and updated policies and procedures for all staff by 03/11/2024 Exit Interview