Inspection Report
Annual Inspection
Census: 50
Capacity: 60
Deficiencies: 3
Aug 20, 2024
Visit Reason
The inspection was a biennial survey to assess compliance with regulations governing assisted living programs, including infection prevention and control.
Findings
The facility was found not in substantial compliance due to deficiencies in pre-service Alzheimer’s/Dementia training for employees, medication storage security, and incomplete dated release of information authorizations in resident records. Some deficiencies were repeats from a prior survey dated 8/4/2022.
Severity Breakdown
Class III: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Five employees did not have the required minimum of eight hours of clinical orientation for Alzheimer’s/Dementia care. | — |
| Medications were not kept in a locked storage cabinet when not in use; medication cart was found unlocked and room door open. | Class III |
| Four resident records lacked a dated release of information authorization form. | — |
Report Facts
Employees without required Alzheimer’s/Dementia training: 5
Resident records missing dated release authorization: 4
Facility census: 50
Facility total capacity: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Toothaker | Administrator | Interviewed and confirmed lack of documentation for Alzheimer’s/Dementia training and release forms. |
| Employee #1 | Certified Residential Medication Aide (CRMA) | Responsible for medication cart found unlocked and confirmed lock was not engaged. |
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