Inspection Reports for
Charter Senior Living of Hasmer Lake
N168 W22026 MAIN ST, JACKSON, WI, 53037
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
94% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 16, 2025
Visit Reason
A complaint investigation was conducted to determine if Charter Senior Living of Hasmer Lake was in substantial compliance with Wisconsin statutes and administrative codes governing residential care apartment complexes.
Complaint Details
The investigation was complaint-driven and concluded on December 16, 2025. Specific substantiation status is not stated in the report.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 89, resulting in a Statement of Deficiency and imposed forfeiture totaling $650. The operator was ordered to comply with requirements and implement corrective measures to protect tenant health, safety, and rights.
Report Facts
Forfeiture amount: 650
Reduced forfeiture amount: 422.5
Forfeiture breakdown: 500
Forfeiture breakdown: 150
Compliance timeframe: 45
Plan of Correction submission timeframe: 10
Notification timeframe to legal representatives: 5
Investigation report timeframe: 7
Forfeiture payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter. |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 3
Date: Dec 16, 2025
Visit Reason
The Department conducted a complaint investigation triggered by allegations that staff were not assisting tenants when needed and not answering call lights.
Complaint Details
Complaint substantiated. The investigation confirmed staff failed to assist a tenant after a fall and tenants did not receive medications as prescribed.
Findings
Three deficiencies were identified including failure to provide unscheduled care after a tenant fall, medication administration without proper nurse delegation, and tenants missing prescribed medications during a medication pass.
Deficiencies (3)
89.23(1) SERVICES: The provider did not ensure services were provided to meet unscheduled care needs. Tenant 1 was not assisted after sustaining a fall and experienced long delays in summoning help.
89.23(4)(a)2. SERVICES: Medication administration and management by two caregivers were performed without delegation from a nurse or pharmacist.
89.34(16) TENANT RIGHTS: Three tenants missed their 8:00 PM medications on 11/08/2025 due to lack of a medication passer during the evening shift.
Report Facts
Census: 31
Deficiencies identified: 3
Missed medication doses: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver C | Administered medications without nurse or pharmacist delegation. | |
| Caregiver D | Administered medications without nurse or pharmacist delegation. | |
| Regional Director of Operations A | Regional Director of Operations | Interviewed regarding lack of notification of tenant fall and caregiver delegation. |
| Executive Director B | Executive Director | Interviewed regarding lack of notification of tenant fall. |
| Executive Director E | Executive Director | Interviewed regarding missed medication pass on 11/08/2025. |
| Fire Chief B | Fire Chief | Provided incident report regarding tenant fall on 11/07/2025. |
Inspection Report
Re-Inspection
Census: 10
Deficiencies: 0
Date: Sep 17, 2025
Visit Reason
The surveyor conducted two verification visits at Charter Senior Living of Hasmer Lake for Statement of Deficiencies dated 06/24/2025 and 02/04/2025, combining multiple surveys into one revisit survey.
Findings
No deficiencies were identified during this revisit survey. All previous citations were corrected. A $200 revisit fee is being assessed under statutory provisions.
Report Facts
Revisit fee: 200
Inspection Report
Enforcement
Deficiencies: 0
Date: Sep 17, 2025
Visit Reason
A verification visit was conducted to determine if Charter Senior Living of Hasmer Lake was in substantial compliance with Wisconsin statutes and administrative code governing residential care apartment complexes.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 89, resulting in a Statement of Deficiency and an imposed forfeiture of $300. The operator is ordered to comply with requirements and submit a Plan of Correction.
Report Facts
Forfeiture amount: 300
Reduced forfeiture amount: 195
Inspection fee: 200
Forfeiture payment deadline: 10
Plan of Correction submission deadline: 10
Compliance deadline: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the enforcement notice letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Plan of Correction
Census: 40
Deficiencies: 1
Date: Sep 17, 2025
Visit Reason
Surveyor conducted a verification visit to assess compliance with nursing services, medication administration, and management at Charter Senior Living of Hasmer Lake.
Findings
One repeat deficiency was identified related to failure to provide nursing services including medication administration and management. Tenant 1 did not receive prescribed Metoprolol and medication administration was not accurately documented.
Deficiencies (1)
89.23(2)(a)2.c Nursing services: Tenant 1 did not receive prescribed Metoprolol as scheduled and medication administration was not accurately documented. This is a repeat deficiency.
Report Facts
Revisit fee: 200
Missed medication doses: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Interviewed regarding medication administration and documentation for Tenant 1 |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: Jun 27, 2025
Visit Reason
The surveyor conducted a verification visit and complaint investigation triggered by allegations that the provider did not provide routine housekeeping services and failed to administer medications as prescribed.
Complaint Details
The complaint was substantiated. The investigation found the provider failed to provide routine housekeeping services and failed to administer medications as prescribed to tenants, including missed doses of Oxycodone and Lactulose.
Findings
Two deficiencies were identified: the provider failed to ensure tenants received supportive services including routine housekeeping and laundry, and failed to provide nursing services including medication administration and management. The complaint was substantiated and one deficiency was a repeat.
Deficiencies (2)
U116 89.23(2)(a)2.a SERVICES: The provider did not ensure tenants were provided with supportive services, including routine housekeeping and laundry service as promised in the residency agreement.
U118 89.23(2)(a)2.c SERVICES: The provider did not ensure nursing services were provided, including medication administration and management, resulting in missed doses and inaccurate documentation for two tenants.
Report Facts
Census: 36
Revisit fee: 200
Missed Oxycodone doses: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator D | Administrator | Interviewed regarding housekeeping and medication administration concerns. |
| RN A | Registered Nurse | Interviewed and reviewed medication administration concerns and documentation. |
| Clinical Specialist E | Clinical Specialist | Interviewed regarding medication administration delays and documentation. |
| Caregiver B | Caregiver | Interviewed regarding laundry and housekeeping responsibilities. |
| Housekeeper C | Housekeeper | Interviewed about housekeeping workload and schedule. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 27, 2025
Visit Reason
A verification visit and complaint investigation were conducted to determine if Charter Senior Living of Hasmer Lake was in substantial compliance with Wisconsin statutes and administrative codes governing residential care apartment complexes.
Complaint Details
The visit was complaint-related and included a verification visit to determine compliance. Specific substantiation status is not stated.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 89, resulting in a Statement of Deficiency #562W13 and an imposed forfeiture of $440.00. The operator is ordered to comply with requirements and submit a Plan of Correction.
Report Facts
Forfeiture amount: 440
Reduced forfeiture amount: 286
Inspection fee: 200
Days to comply: 45
Days to submit Plan of Correction: 10
Days to pay forfeiture: 10
Days to request hearing: 10
Days to pay revisit fee: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter as Bureau of Assisted Living, Division of Quality Assurance. |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 24, 2025
Visit Reason
A complaint investigation was conducted on June 24, 2025, to determine if Charter Senior Living of Hasmer Lake was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The investigation was complaint-driven and concluded that the facility was not in substantial compliance with applicable statutes and administrative codes.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation and an imposed forfeiture of $940.00. The licensee is ordered to comply with all requirements immediately and maintain substantial compliance within 45 days.
Deficiencies (1)
Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in Statement of Deficiency #81YW11
Report Facts
Forfeiture amount: 940
Reduced forfeiture amount: 611
Forfeiture payment timeframe: 10
Compliance timeframe: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 1
Date: Jun 24, 2025
Visit Reason
Surveyor conducted a complaint investigation at Charter Senior Living of Hasmer Lake from 06/19/2025 to 06/24/2025 following a complaint received on 02/14/2025 alleging concerns with administration of resident medications.
Complaint Details
The complaint was substantiated.
Findings
One deficiency was identified and substantiated related to Resident 1 not receiving medications as prescribed. Resident 1 received incorrect dosages of sliding scale insulin on 24 occasions and Midodrine was not held on 23 occasions when parameters indicated to hold the medication. The facility did not notify the physician when blood sugar was over 451 and the December 2024 MAR did not record sliding scale insulin units administered.
Deficiencies (1)
Resident 1 received incorrect dosage of sliding scale insulin on 24 occasions between 09/01/2024 and 11/30/2024 and Midodrine was not held on 23 occasions when parameters indicated to hold this medication.
Report Facts
Medication errors: 47
Incorrect sliding scale insulin administrations: 24
Midodrine not held: 23
Census: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Clinician Specialist A | Interviewed and confirmed medication administration errors; reported not assisting the community during the error period. | |
| Executive Director B | Interviewed; new to role and did not know Resident 1. | |
| Memory Care Director C | Interviewed; new to role and did not know Resident 1. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 12, 2025
Visit Reason
A complaint investigation and self-report review were conducted on February 12, 2025, to determine if Charter Senior Living of Hasmer Lake was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, concluding a complaint investigation and self-report review. Specific substantiation status is not stated.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency (SOD # FVFI11) and imposed a forfeiture of $700.00 for the identified violations.
Report Facts
Forfeiture amount: 700
Reduced forfeiture amount: 455
Forfeiture tag: TAG N426, DHS Code 83.38(1)(b)
Forfeiture payment timeframe: 10
Compliance timeframe: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Enforcement
Deficiencies: 0
Date: Feb 5, 2025
Visit Reason
A standard survey and verification visit was conducted to determine if Charter Senior Living of Hasmer Lake was in substantial compliance with Wisconsin statutes and administrative codes governing residential care apartment complexes.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 89, resulting in a Statement of Deficiency #562W12 and imposition of a $600 forfeiture. The operator is ordered to comply with all requirements and submit a Plan of Correction.
Report Facts
Forfeiture amount: 600
Reduced forfeiture amount: 390
Inspection fee: 200
Forfeiture payment deadline: 10
Plan of Correction submission deadline: 10
Compliance deadline: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the enforcement notice letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 14
Capacity: 24
Deficiencies: 4
Date: Feb 4, 2025
Visit Reason
An investigation into 5 complaints and a self-report was conducted at Charter Senior Living of Hasmer Lake CBRF on 02/04/2025 with information gathered through 02/12/2025.
Complaint Details
The investigation was triggered by 5 complaints and a self-report. Four of the five complaints were substantiated, including abuse allegations and communication failures regarding resident falls.
Findings
Four of 5 complaints were substantiated. Deficiencies included failure to investigate and document abuse allegations, failure to immediately notify legal representatives of resident falls and injuries, inadequate supervision resulting in a resident lying on the floor for over seven hours, and lack of staff training and policy regarding elevator use causing safety concerns.
Deficiencies (4)
Failure to ensure safety of residents and maintain documentation of investigation for abuse allegations involving caregiver CG-D.
Failure to immediately notify residents' legal representatives of falls and injuries, including Resident 4's fractured hip and multiple falls of Resident 6.
Failure to provide supervision appropriate to Resident 6's needs, resulting in Resident 6 lying on the bedroom floor for over seven hours without assistance.
Failure to ensure a safe, clean, comfortable, and homelike environment due to lack of staff training and policy on elevator use, resulting in residents being stuck and requiring fire department assistance.
Report Facts
Complaints investigated: 5
Complaints substantiated: 4
Resident falls: 12
Residents on second floor: 8
Residents needing mobility assistance on second floor: 6
Licensed capacity: 24
Hours resident lay on floor: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CG - D | Caregiver | Named in abuse investigation and termination following substantiated abuse allegations. |
| ED - A | Executive Director | Interviewed regarding abuse investigations and notification failures. |
| OS - B | Operations Specialist | Interviewed regarding abuse investigations and notification failures. |
| HWD - C | Health and Wellness Director | Resigned prior to investigation; involved in abuse investigation. |
| Former Caregiver F | Caregiver | Failed to perform required safety checks resulting in resident lying on floor; terminated. |
| ESD - J | Environmental Services Director | Interviewed regarding elevator operation and lack of staff training. |
| Team Lead/Caregiver-K | Team Lead/Caregiver | Interviewed regarding elevator incident and lack of training. |
| Regional Director of Operations L | Regional Director of Operations | Interviewed regarding elevator policy and training. |
Inspection Report
Routine
Census: 37
Deficiencies: 1
Date: Feb 4, 2025
Visit Reason
A standard survey and verification visit was conducted at Charter Senior Living of Hasmer Lake to assess compliance with regulatory requirements.
Findings
The provider did not ensure tenant health and safety was protected in the event of an emergency, including failure to respond to tenant calls for help within an appropriate timeframe. This was a repeat violation with multiple documented instances of delayed staff response times.
Deficiencies (1)
89.23(2)(c) SERVICES: The provider did not ensure tenant health and safety was protected in emergencies, failing to respond to 8 of 8 tenant calls for help for more than 25 minutes. This is a repeat deficiency.
Report Facts
Revisit fee: 200
Census: 37
Response times: 220
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E | Environmental Service Director | Provided call logs and toured facility with surveyor |
| F | Executive Director | Interviewed regarding staff response expectations and scheduling |
| H | Caregiver | No call no show on 01/31/2025 PM shift |
| I | Caregiver | Off for graduation on 01/31/2025 PM shift |
| A | Regional Operations | Acknowledged concerns and communicated with Executive Director |
| D | Regional Clinical Specialist | Present at exit interview |
| G | Regional Director of Operations | Acknowledged concerns and emailed Executive Director about immediate actions |
Inspection Report
Enforcement
Deficiencies: 0
Date: Jun 14, 2024
Visit Reason
A complaint investigation was conducted to determine if Charter Senior Living of Hasmer Lake was in substantial compliance with Wisconsin statutes and administrative codes governing residential care apartment complexes.
Complaint Details
The visit was complaint-related and concluded on June 14, 2024. The investigation determined noncompliance with applicable statutes and administrative codes. Specific substantiation status is not stated.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 89, resulting in a Statement of Deficiency and an imposed forfeiture of $400.00. The operator is ordered to comply with all requirements and submit a Plan of Correction within specified timeframes.
Report Facts
Forfeiture amount: 400
Reduced forfeiture amount: 260
Forfeiture payment deadline: 10
Plan of Correction submission deadline: 10
Compliance deadline: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter. |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 1
Date: Jun 14, 2024
Visit Reason
Surveyor conducted a complaint investigation from 06/11/2024 to 06/14/2024 at Charter Senior Living of Hasmer Lake regarding an allegation that the provider did not provide prompt care when a tenant called for help.
Complaint Details
The complaint was substantiated. Tenant 1 called for assistance on 03/22/2024 at 1:31 a.m. but was not helped until after 3:34 a.m. Staff attempted to locate Tenant 1 after the call light was activated, finding Tenant 1 lying on the bathroom floor. Tenant 1 was hospitalized with bruising and later transitioned to inpatient hospice.
Findings
One deficiency was identified and substantiated. The provider failed to ensure tenant health and safety was protected in the event of an emergency, as Tenant 1 called for assistance but did not receive help for over 90 minutes.
Deficiencies (1)
89.23(2)(c) SERVICES: The provider did not ensure tenant health and safety was protected in an emergency. Tenant 1 called for help but did not receive assistance for greater than 90 minutes.
Report Facts
Census: 20
Delay in assistance: 90
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 11, 2024
Visit Reason
A complaint investigation and verification visit were conducted on June 11, 2024, at Charter Senior Living of Hasmer Lake to determine if the facility was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, conducted to verify compliance with Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The Department issued a Statement of Deficiency for violations found and required corrective action.
Findings
The Department issued a Statement of Deficiency (SOD #RT4K12) for violations found during the complaint investigation. The licensee was ordered to comply with all requirements immediately and maintain substantial compliance within 45 days. Additionally, a $200 inspection fee was assessed for a subsequent verification visit to determine if prior violations were corrected.
Report Facts
Inspection fee: 200
Timeframe for compliance: 45
Appeal timeframe: 10
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter regarding the violation and order to comply |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 4
Date: Jun 11, 2024
Visit Reason
Surveyor conducted 2 complaint investigations and a verification visit at Charter Senior Living of Hasmer Lake, a CBRF in Jackson, including allegations of injuries with no explanation and failure to notify legal representatives of incidents.
Complaint Details
Two complaint investigations were conducted. One complaint was substantiated regarding failure to investigate injuries and notify legal representatives. One complaint was unsubstantiated.
Findings
Four deficiencies were identified, including failure to investigate injuries of unknown source, failure to notify legal representatives of incidents, failure to reassess scheduled psychotropic medications quarterly for 3 residents, and failure to maintain blood sugar records for 2 residents. One complaint was substantiated and one was unsubstantiated.
Deficiencies (4)
Provider did not ensure an injury of an unknown source was investigated for Resident 7 found with injuries on 03/07/2024.
Provider did not ensure legal representatives for 2 residents were immediately notified of incidents or injuries, including Resident 7 and Resident 4.
Provider did not ensure 3 residents were reassessed quarterly for scheduled psychotropic medications; Residents 1, 4, and 5 had no assessments in past 90 days.
Provider did not maintain blood sugar records for Residents 1 and 6; documentation of blood sugar readings was missing for multiple dates.
Report Facts
Revisit fee: 200
Deficiencies identified: 4
Residents reviewed for psychotropic reassessment: 3
Residents with missing blood sugar records: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator D | Administrator | Discussed concerns regarding injuries and notification failures; stated not employed at time of some incidents. |
| Clinical Specialist E | Clinical Specialist | Interviewed regarding lack of injury investigation and psychotropic medication reassessments; stated no documentation of investigation and that management was taken over in April. |
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 0
Date: Mar 8, 2024
Visit Reason
Surveyor conducted a verification visit to confirm correction of previous deficiencies.
Findings
All previous deficiencies were corrected. No deficiencies were identified during this visit.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 8, 2023
Visit Reason
A complaint investigation and standard survey were conducted on November 8, 2023, to determine if Cedarhurst of Jackson was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, concluding a complaint investigation and standard survey to assess compliance with applicable statutes and administrative codes. Specific substantiation status is not stated.
Findings
The Department issued a Statement of Deficiency (SOD #RT4K11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation, Order to Comply, Special Orders, and a forfeiture of $700.00.
Report Facts
Forfeiture amount: 700
Reduced forfeiture amount: 455
Forfeiture breakdown N389: 400
Forfeiture breakdown N454: 300
Compliance timeframe: 45
Compliance notification timeframe: 7
Extension request timeframe: 10
Forfeiture payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter. |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 6
Date: Nov 8, 2023
Visit Reason
Surveyor conducted a complaint investigation and standard survey at Cedarhurst of Jackson, a CBRF in Jackson, to investigate a complaint and assess compliance with regulatory requirements.
Complaint Details
The complaint was unsubstantiated.
Findings
Six deficiencies were identified, including failure to update resident assessments after changes in condition, failure to update individual service plans upon changes, lack of quarterly reassessment of psychotropic medications, failure to document refusals of blood sugar monitoring and medication administration, lack of pet vaccination records, and improper handling of soiled laundry in food service areas. The complaint was unsubstantiated.
Deficiencies (6)
Provider did not ensure 2 of 3 residents reviewed were assessed when they had a change in condition; Resident 2 and Resident 3 did not have updated fall assessments.
Provider did not ensure 1 of 3 resident individual service plans was updated upon changes; Resident 2's ISP did not include behavior of refusing cares.
Provider did not ensure 1 of 1 residents reviewed were reassessed quarterly for psychotropic medications; Resident 1's use of Citalopram and Quetiapine Fumarate was not reassessed quarterly.
Provider did not ensure the facility cat was vaccinated against diseases, including rabies.
Provider did not ensure refusals of blood sugar monitoring and medication administration were documented in 1 of 3 resident records reviewed; Resident 1's refusals and missed medication administrations were not documented.
Provider did not ensure soiled laundry was not transported in areas used for serving food; soiled laundry was observed in the 2nd floor dining room near residents eating lunch.
Report Facts
Deficiencies identified: 6
Repeat deficiencies: 2
Resident refusals for bathing: 13
Resident refusals for changing clothing: 55
Resident refusals for blood sugar checks: 6
Missed medication administrations: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing B | Director of Nursing | Interviewed regarding Resident 2 and Resident 3's fall assessments, Resident 2's behaviors and ISP, Resident 1's medication and blood sugar monitoring refusals, and laundry handling observations. |
| Regional Nurse C | Regional Nurse | Interviewed regarding Resident 2 and Resident 3's fall assessments, Resident 2's behaviors and ISP, Resident 1's medication and blood sugar monitoring refusals, and laundry handling observations. |
| Interim Administrator A | Interim Administrator | Interviewed regarding the facility cat vaccination records. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 8, 2023
Visit Reason
A complaint investigation and verification visit were conducted to determine if Cedarhurst of Jackson was in substantial compliance with Wisconsin statutes and administrative codes governing residential care apartment complexes.
Complaint Details
The visit was complaint-related, conducted to verify compliance with applicable statutes and administrative codes. Specific substantiation status is not stated.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 89 as detailed in Statement of Deficiency #0H1N13. A total forfeiture of $600 was imposed for these violations, with a reduced forfeiture option of $390 if not appealed.
Report Facts
Forfeiture amount: 600
Reduced forfeiture amount: 390
Forfeiture per violation: 200
Inspection fee: 200
Days to pay forfeiture: 10
Days to submit plan of correction: 10
Days to achieve compliance: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter as Bureau of Assisted Living Director. |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 3
Date: Sep 8, 2023
Visit Reason
Surveyor conducted two complaint investigations and a verification visit at Cedarhurst of Jackson following complaints alleging concerns with tenant care.
Complaint Details
One complaint was substantiated regarding tenant care and missing risk agreement. One complaint was unsubstantiated.
Findings
Three deficiencies were identified, including one repeat violation. One complaint was substantiated and one was unsubstantiated. Deficiencies involved failure to have a signed risk agreement for a tenant with multiple documented falls, incomplete caregiver background checks, and failure to obtain criminal complaint documentation for an employee charged with disorderly conduct.
Deficiencies (3)
89.28(1) Risk Agreement: The provider did not enter into a signed, jointly negotiated risk agreement with Tenant 7 by the date of occupancy despite documentation of 16 falls and high fall risk.
50.065(2)(b) Entity Background Check Requirements: The provider did not ensure Caregiver G's background check was conducted every four years; the last complete check was due in March 2023.
50.065(2)(bb) Determine Final Disposition of Charge: The provider did not make reasonable efforts to obtain criminal complaint and judgment documentation for Caregiver H, who was charged with disorderly conduct.
Report Facts
Census: 35
Documented falls: 16
Revisit fee: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver G | Caregiver | Named in deficiency for missing four-year background check |
| Caregiver H | Caregiver | Named in deficiency for failure to obtain criminal complaint documentation after disorderly conduct charge |
| Executive Director A | Executive Director | Acknowledged missing risk agreement and background check issues during exit conference |
| Wellness Director F | Wellness Director | Participated in exit conference and acknowledged findings |
| Business Office Manager E | Business Office Manager | Responsible for background checks and noted failure to obtain criminal complaint for Caregiver H |
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