Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 3
Aug 1, 2024
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with state regulations including quality improvement, employee orientation and training, and Alzheimer's and dementia program requirements.
Findings
The facility failed to provide evidence of a resident satisfaction survey and Quality Improvement Program, did not ensure completion of required employee orientation for 2 of 5 employees reviewed, and failed to document 16 hours of on-the-job training in memory care for 5 caregivers.
Severity Breakdown
Type 3: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to present evidence of resident satisfaction survey and Quality Improvement Program affecting all 31 residents. | Type 3 |
| Failure to ensure completion of employee orientation as required for 2 employees (E8, E9) out of 5 reviewed. | Type 3 |
| Failure to ensure completion of 16 hours of on-the-job training in memory care for 5 caregivers (E6, E7, E8, E9, E10). | Type 3 |
Report Facts
Resident census: 31
Employees missing orientation training: 2
Caregivers missing memory care training: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Involved in receiving requests and acknowledging missing documentation |
| E2 | Director of Nursing | Presented with written request for documentation |
| E3 | Assistant Director of Nursing | Presented with written request for documentation |
| E8 | Certified Nursing Assistant | Missing documentation of orientation and disaster preparedness training |
| E9 | Certified Nursing Assistant | Missing documentation of orientation, resident rights, HIPAA, disaster preparedness, and abuse training |
| E11 | Human Resources | Responsible for employee files and training documentation; acknowledged missing training |
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