Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 0
Jun 28, 2024
Visit Reason
Surveyor conducted a complaint investigation at Brookdale Onalaska.
Findings
The complaint was unsubstantiated and no deficiencies were identified.
Complaint Details
Complaint was unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
May 26, 2023
Visit Reason
An abbreviated survey was conducted on May 26, 2023, to determine if Brookdale Onalaska was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD) #07VD11 for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, establishing grounds for regulatory action and requiring the licensee to comply with operational standards to protect resident health, safety, and welfare.
Report Facts
Compliance timeframe: 45
Inspection fee: 200
Posting duration: 90
Appeal timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William R. Gardner | Assisted Living Regional Director | Contact person for questions about the letter |
| Kathleen D. Lyons | Interim Assisted Living Director | Signed the notice and order letter |
Inspection Report
Abbreviated Survey
Census: 13
Capacity: 20
Deficiencies: 3
May 24, 2023
Visit Reason
An abbreviated licensure survey was conducted to assess compliance with caregiver background checks, fire safety, and combustible material placement.
Findings
Three deficiencies were identified: a caregiver background check was not timely completed, combustible materials were found within three feet of a gas furnace, and the facility did not have a current annual fire inspection as required.
Deficiencies (3)
| Description |
|---|
| Caregiver C did not have a timely caregiver background check on file. |
| Combustible items were placed within three feet of a gas furnace in a mechanical room. |
| The facility did not have an annual fire inspection completed for 2022 or 2023 as required. |
Report Facts
Deficiencies identified: 3
Census: 13
Total licensed capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Interviewed regarding caregiver background check and combustible materials | |
| Maintenance Person B | Provided facility safety book and information about fire inspections |
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