Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
75% occupied
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Follow-Up
Census: 27
Deficiencies: 2
Date: Dec 5, 2025
Visit Reason
Verification visit conducted to assess correction of previously identified deficiencies related to medication administration and documentation.
Findings
Two deficiencies were identified, both repeat violations. The provider failed to document the need and response for as-needed medications for multiple residents and did not ensure medication administration met residents' needs, including incorrect insulin dosages and failure to administer prescribed Polyethylene Glycol.
Deficiencies (2)
83.37(2)(d) Documentation of medication administration. The provider did not document the need and/or response of as-needed medications for 4 of 4 residents reviewed, including failure to record sliding scale insulin units on 8 occasions for Resident 10.
83.38(1)(h) Medication administration. The provider did not ensure 3 of 4 residents received medication administration services to meet their needs, including incorrect sliding scale insulin dosages for Resident 10 and failure to administer Polyethylene Glycol as ordered for Residents 18 and 19.
Report Facts
Revisit fee: 200
Residents with undocumented PRN medication need/response: 4
Sliding scale insulin undocumented occurrences: 8
Sliding scale insulin incorrect dosages: 6
Polyethylene Glycol doses administered exceeding container supply: 46
Polyethylene Glycol doses administered exceeding container supply: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Administrator | Interviewed regarding medication administration concerns. |
| JJ | VP of Clinical Operations | Interviewed and acknowledged medication administration issues; plans to reeducate staff. |
| KK | Regional RN | Interviewed regarding medication administration concerns. |
| Wellness Director II | Interviewed and acknowledged medication administration issues; responsible for medication cart audits. |
Inspection Report
Enforcement
Deficiencies: 1
Date: Dec 5, 2025
Visit Reason
A verification visit was conducted to determine if Hartland Place was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency for violations related to medication administration and management. A forfeiture of $1900 was imposed for these violations, with a reduced payment option of $1235. The licensee is ordered to comply with all requirements and provide staff training on medication administration within 45 days.
Deficiencies (1)
Wis. Stat. § 50.03(5g)(b)6. requires the licensee to protect and promote each resident’s right to receive all prescribed medications as prescribed. The licensee must develop and implement corrective measures related to medication administration and management within 45 days.
Report Facts
Forfeiture amount: 1900
Reduced forfeiture amount: 1235
Inspection fee: 200
Forfeiture amount for tag N415: 1200
Forfeiture amount for tag N432: 700
Compliance timeframe: 45
Appeal timeframe: 10
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 13, 2025
Visit Reason
A standard survey and complaint investigation were conducted to determine if Hartland Place was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related and included a standard survey and complaint investigation to assess compliance with Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The Department found violations substantiated as detailed in SOD #QPFI15.
Findings
The Department issued a Statement of Deficiency (SOD #QPFI15) for violations related to medication administration and management, resulting in an order to comply with requirements and corrective training measures. A forfeiture of $2,940 was imposed for multiple violations, with a reduced payment option of $1,911. Additionally, a $200 inspection fee was assessed for a verification visit.
Deficiencies (1)
Deficiency related to medication administration and management as identified in Statement of Deficiency QPFI15.
Report Facts
Forfeiture amount: 2940
Reduced forfeiture amount: 1911
Forfeiture amount for tag N239: 400
Forfeiture amount for tag N277: 400
Forfeiture amount for tag N389: 600
Forfeiture amount for tag N432: 1540
Inspection fee: 200
Revisit fee: 200
Compliance timeframe: 45
Extension request timeframe: 10
Forfeiture payment due timeframe: 10
Revisit fee payment due timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter. |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 8
Date: May 13, 2025
Visit Reason
Surveyors conducted a complaint investigation, standard survey, and verification visit at Hartland Place from 05/07/2025 to 05/13/2025. The complaint was substantiated and a $200 revisit fee was assessed.
Complaint Details
The complaint was substantiated. The investigation revealed multiple deficiencies including medication administration errors and inadequate staff training.
Findings
Eight deficiencies were identified, six of which were repeat violations. Deficiencies included failure to ensure employee communicable disease screening and training, incomplete individual service plans, inadequate documentation and administration of medications, and failure to maintain clean and odor-free resident rooms.
Deficiencies (8)
Failure to obtain documentation that an employee was screened for communicable disease including tuberculosis.
Failure to ensure an employee completed required department-approved training courses including standard precautions within 90 days of employment.
Failure to ensure continuing education requirements were met by staff.
Failure to involve residents and legal representatives in development of individual service plans; missing signatures on plans.
Failure to update individual service plan to include resident's behavior of refusing morning medications.
Failure to document need and response for PRN medications for residents.
Failure to provide appropriate medication administration; multiple residents did not receive ordered medications or had medication errors.
Failure to keep resident rooms clean and free from odors; observed soiled briefs, fecal matter, strong odors, and stained carpets in resident rooms.
Report Facts
Deficiencies identified: 8
Repeat violations: 6
Revisit fee: 200
Resident refusals of insulin and blood sugar checks: 17
Continuing education hours: 15
Acetaminophen administrations missing response documentation: 2
Hydrocodone administrations missing response documentation: 4
Lorazepam administrations missing response documentation: 4
Acetaminophen-Codeine doses not administered: 7
Polyethylene glycol administrations documented: 93
Polyethylene glycol administrations documented: 38
Polyethylene glycol administrations documented: 100
Polyethylene glycol administrations documented: 13
Chlorhexidine gluconate mouthwash administrations documented: 130
Chlorhexidine gluconate mouthwash refusals: 20
Chlorhexidine gluconate mouthwash not available: 43
Polyethylene glycol administrations documented: 57
Polyethylene glycol refusals: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver DD | Named in deficiencies related to missing communicable disease screening and incomplete training. | |
| Caregiver GG | Named in deficiencies related to medication administration errors and incomplete continuing education. | |
| Caregiver FF | Interviewed regarding Resident 10's medication refusals and medication cart inspections. | |
| Administrator BB | Administrator | Interviewed regarding multiple deficiencies including training, medication administration, and room cleanliness. |
| Regional Wellness Director CC | Regional Wellness Director | Interviewed regarding multiple deficiencies including training, medication administration, and room cleanliness. |
| Pharmacy Tech HH | Pharmacy Technician | Interviewed regarding medication dispensing and refill processes. |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Date: Jan 22, 2024
Visit Reason
The surveyor conducted a complaint investigation and verification visit at Hartland Place following a complaint alleging concerns with falls during toileting.
Complaint Details
The complaint was substantiated. The complaint alleged concerns with falls during toileting. A $200 revisit fee is being assessed under statutory provisions of Wis. Stat. Ch50.
Findings
One deficiency was identified related to the individual service plan (ISP) not being updated when there was a change in resident needs and abilities. The complaint was substantiated and the deficiency was a repeat violation from a prior survey dated 06/15/2022.
Deficiencies (1)
Individual service plan (ISP) was not updated for Resident 5 when there was a change in assistance during toileting.
Report Facts
Revisit fee: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding Resident 5's toileting and ISP update after fall incident |
| Caregiver AA | Caregiver | Interviewed regarding Resident 5's assistance needs and use of call pendant |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
A complaint investigation and verification visit were conducted on January 18, 2024, to determine if Hartland Place 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 applicable statutes and codes. The Department issued a Statement of Deficiency (SOD #QPFI14) based on the investigation.
Findings
The Department issued a Statement of Deficiency (SOD #QPFI14) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements to update residents' Individual Service Plans and ensure staff adherence to these plans to protect residents' health and safety.
Report Facts
Inspection fee: 200
Compliance timeframe: 45
Extension request timeframe: 10
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter. |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Enforcement
Deficiencies: 0
Date: Sep 21, 2023
Visit Reason
A verification visit was conducted on September 21, 2023, to determine if Hartland Place was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83 at Hartland Place, resulting in a Statement of Deficiency #QPFI13 and the imposition of a forfeiture totaling $1600.00. The licensee is ordered to comply with all requirements within 45 days and is subject to a $200 inspection fee for a revisit to verify compliance.
Report Facts
Forfeiture amount: 1600
Reduced forfeiture amount: 1040
Compliance timeframe: 45
Inspection fee: 200
Revisit fee: 200
Appeal timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Follow-Up
Census: 31
Deficiencies: 2
Date: Sep 21, 2023
Visit Reason
The surveyor conducted a verification visit to Hartland Place to verify compliance with previously identified deficiencies and employee training requirements.
Findings
Two deficiencies were identified, including a repeat violation related to incomplete employee training for client groups and challenging behaviors. Additionally, medication administration was found to be inappropriate for two residents due to unavailable medications and lack of documented communication with physicians.
Deficiencies (2)
Failure to ensure that 2 of 2 employees completed all required training in client groups and challenging behaviors within 90 days of hire.
Failure to ensure medication administration was appropriate for 2 of 2 residents reviewed, with medications not available and lack of documented communication with physicians.
Report Facts
Revisit fee: 200
Number of deficiencies identified: 2
Number of employees reviewed for training: 2
Number of residents reviewed for medication administration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Provided information about employee training schedule and medication ordering process; acknowledged training deficiencies. | |
| Caregiver Z | Employee without documented completion of required training in client groups and challenging behaviors. | |
| Caregiver AA | Employee without documented completion of required training in client groups and challenging behaviors. |
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