Inspection Reports for
Brookdale Lacrosse AL
3141 EAST AVE SOUTH, LACROSSE, WI, 54601
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
78% occupied
Based on a March 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 16, 2026
Visit Reason
A complaint investigation was conducted to determine if Brookdale LaCrosse AL was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The investigation was complaint-driven and concluded on March 16, 2026. The Department found violations and issued a Statement of Deficiency #KV5Q11.
Findings
The Department issued a Statement of Deficiency for violations related to medication administration and other regulatory requirements. A total forfeiture of $4200 was imposed for these violations, with corrective measures ordered to ensure proper care and treatment of residents.
Deficiencies (1)
Violation of Wis. Admin. Code ch. DHS 83 related to medication administration deficiencies requiring corrective measures within 45 days.
Report Facts
Forfeiture amount: 4200
Reduced forfeiture amount: 2730
Forfeiture for tag N 230: 200
Forfeiture for tag N 352: 3800
Forfeiture for tag Y 3244: 200
Compliance timeframe for corrective measures: 45
Compliance timeframe for notification: 7
Payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Haugen | Assisted Living Regional Director | Contact person for questions about the letter. |
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter. |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 36
Deficiencies: 5
Date: Mar 16, 2026
Visit Reason
Surveyors conducted 8 complaint investigations at Brookdale Lacrosse AL from 03/04/2026 to 03/16/2026, with four complaints substantiated.
Complaint Details
The investigation was triggered by complaints alleging medication errors, lack of staff training, failure to notify POAHC of resident falls and ER visits, and inadequate resident care.
Findings
Five deficiencies were identified including failure to provide orientation training to agency staff, medication administration errors resulting in missed doses for multiple residents, inaccurate medication documentation, incomplete resident records, and inadequate care coordination for a hospice resident.
Deficiencies (5)
N 230 Orientation: The provider did not ensure agency staff received orientation training prior to performing job duties as required by DHS 83.19.
N 352 Rights of Residents: The provider did not ensure residents received all prescribed medications in the correct dosages and intervals, with multiple residents missing doses due to medication unavailability or delayed re-ordering.
N 415 Documentation of medication administration: Resident 4's medication administration record was inaccurate, with doses documented as given when medication was not available.
N 454 Resident record maintained: Resident 3's record lacked documentation of an activated power of attorney for healthcare (POAHC).
Y3244 Residents' rights: The provider did not ensure Resident 3 received adequate care, relying on EMTs for transfers despite paying for 2-person mechanical lift assistance, and failed to follow hospice orders resulting in unnecessary ER visits.
Report Facts
Complaints investigated: 8
Complaints substantiated: 4
Deficiencies identified: 5
Resident census: 28
Total licensed capacity: 36
Medication doses missed: 117
Agency staff shifts: 70
Supplemental services fee: 1715
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 0
Date: Aug 14, 2025
Visit Reason
Surveyor conducted a complaint investigation at Brookdale La Crosse AL.
Complaint Details
The complaint was unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were identified.
Inspection Report
Follow-Up
Census: 24
Deficiencies: 0
Date: Feb 11, 2025
Visit Reason
The surveyor conducted a verification visit to confirm correction of a previously identified deficiency from the Statement of Deficiency dated 08/09/2024.
Findings
The previously identified deficiency was corrected and no new deficiencies were identified during this visit. A $200 revisit fee is being assessed under statutory provisions.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 9, 2024
Visit Reason
A standard survey and complaint investigation were conducted to determine if Brookdale LaCrosse AL was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related as it included a complaint investigation; however, the substantiation status is not stated.
Findings
The Department issued a Statement of Deficiency (SOD #HZDD11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, establishing grounds for enforcement action and requiring the licensee to comply with all requirements to protect resident health, safety, and welfare.
Report Facts
Compliance timeframe: 45
Inspection fee: 200
Appeal timeframe: 10
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William R. Gardner | Assisted Living Regional Director | Contact person for questions about the letter |
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 36
Deficiencies: 1
Date: Aug 9, 2024
Visit Reason
The inspection was conducted as an anonymous complaint investigation and a standard survey at Brookdale La Crosse AL following a complaint received on 2024-07-14 regarding medication errors that resulted in a resident being sent to a hospital.
Complaint Details
The complaint was substantiated. Resident 1 was administered another resident's medication in error, resulting in an emergency room visit for observation due to possible side effects. The incident was investigated but not documented. Hospital progress and discharge notes confirmed the medication error and subsequent symptoms.
Findings
The provider did not ensure Resident 1's right to receive all medications as prescribed when Resident 1 was given Resident 2's morning medications, resulting in Resident 1 being drowsy and requiring emergency room observation for approximately 3 hours. The complaint was substantiated with one deficiency identified.
Deficiencies (1)
The provider did not ensure Resident 1's right to receive all medications as prescribed when Resident 1 was given Resident 2's AM medications.
Report Facts
Census: 21
Total licensed capacity: 36
Duration of emergency room observation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding hospitalization after medication error |
| Health and Wellness Director B | Health and Wellness Director | Interviewed regarding investigation and symptoms after medication error |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 14, 2024
Visit Reason
A complaint investigation was conducted on February 14, 2024, to determine if Brookdale Lacrosse AL was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The complaint was concluded on February 14, 2024, resulting in findings of noncompliance and issuance of a Statement of Deficiency. Specific substantiation status is not stated.
Findings
The Department issued a Statement of Deficiency (SOD #2PFF11) 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 all requirements within 45 days.
Report Facts
Days to achieve compliance: 45
Appeal filing deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William R. Gardner | Assisted Living Regional Director | Contact person for questions about the letter. |
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter. |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 36
Deficiencies: 2
Date: Feb 14, 2024
Visit Reason
The inspection was conducted as a complaint investigation following two complaints received by the Department on 01/30/2024 regarding untimely refund of resident deposits and lack of cleanliness in resident bathrooms and living areas.
Complaint Details
Two complaints were substantiated: one regarding untimely refund of deposits to Resident 1, and another regarding lack of cleanliness in Resident 2's bathroom and living area.
Findings
Two deficiencies were identified and substantiated: the provider did not return all refunds due to a resident within 30 days of discharge, and the provider failed to maintain a safe, clean, comfortable, and homelike environment, specifically evidenced by an unclean toilet in a resident's bathroom.
Deficiencies (2)
Provider did not return all refunds due to Resident 1 within 30 days of discharge, with a community fee refunded late on 01/11/2024.
Provider did not ensure the bathroom area for Resident 2 was clean; feces were observed stuck on the back of the toilet bowl during the inspection.
Report Facts
Census: 21
Total licensed capacity: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Interviewed regarding refund delays and cleanliness issues |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
Surveyor conducted a complaint investigation at Brookdale La Crosse AL on 03/30/2023.
Complaint Details
The complaint was unsubstantiated.
Findings
The complaint was unsubstantiated and no new deficiencies were identified during the investigation.
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 0
Date: Feb 24, 2023
Visit Reason
Surveyor conducted a complaint investigation at Brookdale La Crosse AL on 02/24/2023.
Complaint Details
Complaint was investigated and found not substantiated.
Findings
The complaint was not substantiated and no deficiencies were identified during the investigation.
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