Facility Evaluation Report

A Noncompliance Conference (NCC) was conducted today, via Microsoft Teams. The purpose of the NCC was to discuss the facilities substantiated non compliance. Present at today’s NCC were the Regional Office Manager Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analysts (LPA) Kesha Lewis and Kathryn Thomas, Long term Care Ombudsman and Administrator Mary Margaret Chappell as representative for the Licensee, Sara (Health and wellness Director) also on the meeting was Grace Ndomo( District Director) Kadi Berry (District Director), Andrew Lindner (Privacy Officer) and Joel Goldman (Attorney). The administrative process was explained during this meeting and Licensee was informed that further citations may result in Administrative Action.

Issues discussed related to the above include :

1. A plan ensuring appropriate supervision based on residents’ specific needs

2. Ensure completed staff training on the topic of care and supervision

3. Proper assessment of residents upon admission and reappraisals

4. Appropriate and timely communication resident physicians and family members And when to call 911

5. Ongoing medication training and reporting requirements

Exit interview conducted and report provided.