The most recent inspection on July 14, 2025, identified deficiencies related to residency requirements, disaster preparedness drills, employee record updates, tuberculosis risk assessments, and dementia-specific training. Earlier inspections showed similar issues with residency compliance, disaster preparedness, employee background checks, and training programs. Prior reports from August 23, 2024, cited deficiencies in securing hazardous compounds in the memory care unit, which were addressed with corrective actions and staff training. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports, and no complaint investigations were noted. The pattern of findings suggests ongoing challenges in regulatory compliance, particularly in resident care documentation and safety training, with some corrective measures taken but recurring issues remaining.
Deficiencies (last 2 years)
Deficiencies (over 2 years)6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Annual Licensure Survey conducted to assess compliance with residency requirements, disaster preparedness, health care worker background checks, tuberculosis screening, and Alzheimer's/dementia program training.
Findings
The facility was found deficient in multiple areas including failure to meet residency requirements for one resident, incomplete tornado drills on all shifts, failure to update employee hire dates in the Registry Portal for four employees, lack of documented annual TB risk assessment for one resident, and inadequate dementia-specific orientation training for one employee in the Memory Care unit.
Severity Breakdown
Type 3 Violation: 3Type 2 Violation: 1
Deficiencies (5)
Description
Severity
Failed to ensure residency requirements are met for one resident requiring extensive assistance and hospice care.
Type 3 Violation
Failed to conduct tornado drills on all shifts during February as required.
—
Failed to update the Registry Portal to include employee hire dates for four employees.
Type 3 Violation
Failed to ensure documented annual TB risk assessment or TB signs and symptoms check for one resident.
Type 2 Violation
Failed to ensure four hours of dementia-specific orientation prior to assuming job responsibilities without direct supervision for one employee in the Memory Care unit.
Type 3 Violation
Report Facts
Employee hire dates missing: 4Tornado drills conducted: 3Resident reviewed for residency requirements: 3Resident reviewed for TB risk assessment: 3Hours of dementia-specific orientation training completed: 0.75
Employees Mentioned
Name
Title
Context
E8
Care Partner
Named in deficiency for incomplete dementia-specific orientation training.
E3
Director of Nursing
Confirmed resident R1's condition and discussed staff orientation training.
E6
Facilities Manager
Reported tornado drills had not been conducted this year.
E5
Human Resources Generalist
Confirmed Registry Portal was not updated with employee hire dates.
E13
Care Partner
Observed assisting resident R1 with mobility and care.
E14
Infection Control Nurse
Reported resident R2's TB skin test was not done due to adverse reaction and assessment was not documented.
The document is related to the Annual Assisted Living Licensure Survey conducted on 7/14/2025 at The Admiral at the Lake.
Findings
The report includes evidence of correction and payment of violations from the annual survey. It details corrective actions for deficiencies related to residency requirements, disaster preparedness, health care worker background checks, tuberculosis skin test procedures, and Alzheimer’s and dementia training programs.
Deficiencies (5)
Description
Residency requirements not met for all residents.
Disaster preparedness, specifically related to tornado drills, was deficient.
Health Care Worker Background Checks for Employment Verification were not properly conducted.
Tuberculin (TB) Skin Test Procedures were not fully compliant.
Training for Alzheimer’s and Dementia programs was insufficient.
Report Facts
Date of Survey: Jul 14, 2025Date of Compliance for Residency Requirements: Jul 26, 2025Date of Compliance for Disaster Preparedness: Jul 25, 2025Date of Compliance for Health Care Worker Background Checks: Jul 25, 2025Date of Compliance for TB Skin Test Procedures: Jul 25, 2025Date of Compliance for Alzheimer’s and Dementia Training: Jul 25, 2025
Employees Mentioned
Name
Title
Context
Helen Dittmer
Administrator, Director of Health Services
Named in corrective actions and as the person conducting education and oversight
Chantal Chine
DON
Involved in review of care plans and corrective actions
Karen Clinton
Social Services Coordinator
Named in attendance and corrective action oversight
Daisy Krygowski
Resident Accounts Admin
Named in attendance and corrective action oversight
Merun Varughese
Infection Preventionist
Involved in TB policy review and infection control education
Bethany Tallon
HR Generalist
Involved in employment verification corrective actions
Linda Vestrand
HR Director
Involved in employment verification corrective actions
Annual licensure survey conducted to assess compliance with environmental and safety regulations at the facility.
Findings
The facility failed to secure hazardous compounds in the memory care unit, including unlocked utility room cabinets containing moisturizers labeled as hazardous, presence of dishwashing soap in the kitchen preparation room, and scattered boxes of gloves posing choking hazards. The Chief Operating Officer agreed these items should be secured.
Deficiencies (1)
Description
Facility failed to maintain hazardous compounds secure and out of reach in the memory care unit for 9 residents identified as wanderers.
Report Facts
Residents affected: 9
Employees Mentioned
Name
Title
Context
Chief Operating Officer
Agreed that utility room should be locked, kitchen cleaning detergent should not be accessible, and gloves should be secured
The inspection was an annual survey conducted to assess compliance with licensure and certification requirements, focusing on environmental safety related to hazardous compounds storage in the memory care unit.
Findings
The facility was found to have failed to maintain hazardous compounds secured and out of reach in the memory care unit, with unlocked utility room doors and accessible hazardous cleaning products posing risks to residents identified as wanderers. Immediate corrective actions were taken to secure these hazards, and staff training and monitoring plans were implemented.
Deficiencies (1)
Description
Facility failed to maintain hazardous compounds secure and out of reach in the memory care unit for 9 residents identified as wanderers, including unlocked utility room door and accessible hazardous cleaning products.
Report Facts
Residents affected: 9
Employees Mentioned
Name
Title
Context
Chantel Chine
Director of Nursing
Created daily spot check plan and completed monitoring audits
Sara V. ADON
Assistant Director of Nursing
Co-signed nursing in-service regarding safe keeping of compounds and hazards
Mary Beth Lutjen
Conducted culinary services in-service training on kitchen chemical lock-up
E1
Chief Operating Officer
Agreed that utility room should be locked and hazardous compounds secured
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