Inspection Report Summary
The most recent inspection on July 18, 2024, identified multiple deficiencies related to assessments, staff training, physical examinations, primary care orders, incident reporting, and service plan development for memory care residents. Earlier inspections showed similar issues with medication orders, medical examinations, and service plans, while complaint investigations from 2022 and 2023 found no deficiencies. Prior complaint investigations in 2020 substantiated deficiencies in supervision that led to a resident fall and death, as well as medication management problems. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows recurring challenges with documentation, staff training, and care planning, with no clear trend of improvement in the most recent report.
Deficiencies (last 4 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Inspection Report
RoutineInspection Report
Plan of CorrectionInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Annual InspectionInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lisa Urbanek | Nurse Manager | Named in plan of correction and interview confirming findings |
| Staff A | Interviewed staff involved in medication administration and resident supervision | |
| Staff B | Interviewed staff involved in resident supervision and fall incident | |
| Staff D | Interviewed staff regarding resident mobility and supervision | |
| Staff E | Interviewed staff regarding resident activities and supervision | |
| Staff F | Interviewed staff regarding wheelchair use and resident supervision | |
| Staff G | Interviewed staff regarding wheelchair brake engagement | |
| Staff H | Interviewed staff regarding wheelchair use and resident safety |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lisa Urbanek | Nurse Manager | Named in plan of correction and confirmation of medication administration procedures |
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