Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Capacity: 20
Deficiencies: 1
Aug 29, 2025
Visit Reason
The investigation was initiated due to an allegation that staff member Chad Fender was stealing resident medications from the facility.
Findings
The investigation found evidence that Chad Fender took resident medications out of the facility, including multiple discrepancies in narcotic medication records and refusal to cooperate with medication audits. Chad Fender was suspended and subsequently terminated. The facility filed a complaint with the Attorney General and implemented corrective actions.
Complaint Details
The complaint was substantiated. Chad Fender was found to have stolen medications, resulting in his termination. The facility reported the incident to the Attorney General and law enforcement.
Deficiencies (1)
| Description |
|---|
| Staff member Chad Fender was stealing resident medications out of the facility. |
Report Facts
Discrepancies: 12
Discrepancies: 304
Discrepancies: 170
Facility Capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chad Fender | Health and Wellness Director, Nurse | Named in medication theft allegation and investigation |
| Sarah LeBarre | Administrator and Licensee Designee | Provided information and participated in investigation and exit conference |
| Jennifer Smith | Director of Clinical Services | Interviewed regarding medication discrepancies and internal investigation |
| Brian Welch | Director of Operations, Guardian Pharmacy | Conducted medication audit and reported discrepancies |
| Ondrea Johnson | Licensing Consultant | Conducted investigation and exit conference |
Inspection Report
Renewal
Census: 10
Capacity: 20
Deficiencies: 12
Jun 11, 2025
Visit Reason
The inspection was conducted as a renewal licensing study to verify compliance with licensing statutes and administrative rules and to approve the renewal of the facility's license.
Findings
The facility was found to have multiple deficiencies including lack of required staff training and health documentation, missing resident registers and medication discrepancies, environmental safety issues, and incomplete personnel policies. An acceptable corrective action plan was submitted and approved.
Deficiencies (12)
| Description |
|---|
| Licensee designee unable to verify training in CPR, first aid, and nutrition; administrator unable to verify training in safety, fire prevention, and nutrition. |
| Employee Adrienne Holmes lacks CPR and first aid training documentation. |
| Employee Chad Fender lacks current physical and TB test results on file. |
| Licensee unable to show written employee policies, job descriptions, and verification of receipt. |
| No reference checks for employee Chris Fender available for review. |
| No resident register on file for department review. |
| Resident A missing Acetaminophen 325 mg and Loperamide 2 mg; medications not stored in facility. |
| No Funds I and II forms for any resident maintained in resident files. |
| Water temperature at kitchen faucet exceeds 120 degrees Fahrenheit. |
| Combustible items stored in furnace rooms and feces found on toilet in resident bedroom #4. |
| Bedrooms #6 and #7 combined as one bedroom without required 7-foot horizontal opening. |
| Signature of licensee missing for resident assessment plans and AFC care agreements; Resident A lacks current health care appraisal. |
Report Facts
Facility capacity: 20
Resident census: 10
Staff interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adrienne Holmes | Named in deficiency for lacking CPR and first aid training documentation | |
| Chad Fender | Named in deficiencies for lacking current physical, TB test results, and missing reference checks | |
| Chris Fender | Named in deficiency for missing reference checks | |
| Sarah LeBarre | Administrator | Named as facility administrator; unable to verify training in safety, fire prevention, and nutrition |
Inspection Report
Complaint Investigation
Capacity: 20
Deficiencies: 3
Sep 19, 2024
Visit Reason
The investigation was initiated due to a complaint alleging that Resident A sits in soiled adult diapers for an extended timeframe and does not receive medications as prescribed.
Findings
The allegation that Resident A sits in soiled adult diapers for an extended timeframe was not substantiated based on interviews and review of the resident's assessment plan. However, the allegation that Resident A does not receive medications as prescribed was substantiated due to the absence of certain prescribed medications at the facility. Additional violations were found related to unapproved administrator/licensee designee appointment and missing signatures on the resident's assessment plan.
Complaint Details
Complaint alleged Resident A sits in soiled adult diapers for an extended timeframe and does not receive medications as prescribed. The diaper allegation was not substantiated; the medication allegation was substantiated.
Deficiencies (3)
| Description |
|---|
| Resident A does not receive medications as prescribed due to unavailability of prescribed medications at the facility. |
| Facility failed to report organizational changes regarding the appointment of the new administrator and licensee designee to the department. |
| Resident A's assessment plan lacked signatures or dates verifying review by Resident A and the licensee designee. |
Report Facts
Capacity: 20
Complaint Receipt Date: Sep 4, 2024
Investigation Initiation Date: Sep 6, 2024
Report Due Date: Nov 3, 2024
Corrective Action Plan Due Date: Nov 6, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ann Smith | Executive Director, Acting Administrator and Licensee Designee | Named in findings related to unapproved appointment and organizational changes |
| Ondrea Johnson | Licensing Consultant | Author of the report |
Inspection Report
Complaint Investigation
Capacity: 20
Deficiencies: 1
Dec 11, 2023
Visit Reason
The investigation was initiated due to a complaint alleging that for 2-3 hours on November 23rd into the early morning of November 24th, 2023, there was no staff coverage at the facility, during which a resident requested help and rang their call light without response.
Findings
The investigation confirmed that no direct care staff member was present at Brookdale Delta AL from approximately 10:30pm to 2:00am on November 23-24, 2023. Resident A pushed her call light for assistance, was unable to find staff, and ultimately called 911. The staffing ratio was inadequate during this time, constituting a violation of staffing requirements.
Complaint Details
The complaint alleged that for 2-3 hours on November 23rd into the morning of November 24th, 2023, there was no staff coverage at the facility. This was substantiated by interviews, documentation, and a police report confirming the absence of staff and the resident's call to 911.
Deficiencies (1)
| Description |
|---|
| No direct care staff member was present at the facility for approximately 2-3 hours during the night shift, resulting in inadequate staffing to meet resident needs. |
Report Facts
Capacity: 20
Time without staff coverage: 2.5
911 call time: 1.26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Kate Van Aker | Executive Director | Interviewed regarding staffing mix-up and absence of direct care staff |
| Michael Kegley | Operations Specialist | Interviewed and provided documentation related to the investigation |
| Amanda Spanke | Resident Care Coordinator | Interviewed about scheduling errors and staffing on the date of the incident |
| Shantoria Brown | Direct Care Worker | Interviewed about staffing and on-call phone during the incident |
| Jaleesa Long | Direct Care Worker | Interviewed about shift scheduling and leaving early on the date of the incident |
| Marie Nelson | Direct Care Worker | Interviewed about arriving at the facility and assisting Resident A |
| Benaiah Sams | Direct Care Worker | Interviewed about shift reassignment and staffing on the date of the incident |
Inspection Report
Renewal
Census: 10
Capacity: 20
Deficiencies: 5
Jun 14, 2023
Visit Reason
The inspection was conducted as a Renewal Licensing Study for Brookdale Delta AL to assess compliance with licensing requirements and to determine if the facility meets standards for license renewal.
Findings
The facility was found non-compliant due to lack of a licensee designee and administrator, failure to notify the department of personnel changes, and direct care staff not trained in first aid and CPR. Additionally, one resident did not have an annually updated written Resident Care Agreement.
Deficiencies (5)
| Description |
|---|
| Facility without a licensee designee and administrator and did not inform the department. |
| Facility is without an administrator. |
| Direct care staff Kylene Cortez, Jackie Hallock, and Kalie Cotter were not trained in first aid. |
| Direct care staff Kylene Cortez, Jackie Hallock, and Kalie Cotter were not trained in CPR. |
| Resident A did not have an annually updated written Resident Care Agreement. |
Report Facts
Number of residents interviewed and/or observed: 10
Total licensed capacity: 20
Number of staff interviewed and/or observed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylene Cortez | Direct care staff | Named in findings for lack of first aid and CPR training |
| Jackie Hallock | Direct care staff | Named in findings for lack of first aid and CPR training |
| Kalie Cotter | Direct care staff | Named in findings for lack of first aid and CPR training |
| Eli DeLeon | Licensing Consultant | Author of the inspection report |
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