Inspection Reports for
Mountain Terrace Senior Living Cbrf
3402 TERRACE COURT, WAUSAU, WI, 54401
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
85% 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
Census: 34
Deficiencies: 0
Date: Mar 10, 2026
Visit Reason
Surveyor conducted two complaint investigations at Mountain Terrace Senior Living CBRF.
Complaint Details
Two complaints were investigated and both were found to be unsubstantiated.
Findings
Two complaints were unsubstantiated and no deficiencies were identified during the investigation.
Report Facts
Complaints investigated: 2
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 10, 2025
Visit Reason
A complaint investigation and verification visit were conducted to determine if Mountain Terrace Senior Living CBRF 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 verification visit to determine if prior violations were corrected. The Department imposed a $200 inspection fee for the revisit.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency and imposition of a total forfeiture of $1,150. The licensee was ordered to comply with requirements to protect residents' rights, including proper notification of involuntary discharges.
Deficiencies (4)
Tag N326, DHS Code 83.31(4)(a): The licensee failed to provide a 30 day written advance notice with all required information before involuntarily discharging a resident.
Tag N352, DHS Code 83.32(3)(h): Violation related to administrative or operational requirements as specified in the Statement of Deficiency.
Tag N386, DHS Code 83.35(3)(a): Violation related to resident rights or protections as specified in the Statement of Deficiency.
Tag N388, DHS Code 83.35(3)(c): Violation related to resident rights or protections as specified in the Statement of Deficiency.
Report Facts
Forfeiture amount: 1150
Reduced forfeiture amount: 747.5
Inspection fee: 200
Forfeiture breakdown: 400
Forfeiture breakdown: 150
Forfeiture breakdown: 300
Forfeiture breakdown: 300
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 5
Date: Dec 10, 2025
Visit Reason
Surveyor conducted 3 complaint investigations and a verification visit at Mountain Terrace Senior Living CBRF. Three of 3 complaints were substantiated.
Complaint Details
Three complaints were investigated and substantiated. Complaints included failure to provide discharge notices, medication errors, inadequate care plans, and poor room cleanliness.
Findings
Five deficiencies were identified, including failure to provide 30-day written discharge notices for discharged residents, medication administration errors, incomplete individual service plans, failure to implement service plans, and failure to maintain clean and odor-free resident rooms.
Deficiencies (5)
83.31(4)(a) Notice of facility initiated discharges: The licensee did not give the resident or legal representative a 30-day written advance notice of discharge for 2 discharged residents.
83.32(3)(h) Rights of Residents: Receive medication: Staff did not administer Resident 1's midodrine as prescribed, holding doses incorrectly based on blood pressure readings.
83.35(3)(a) Comprehensive Individualized Service Plan: The provider did not develop a comprehensive individual service plan for Resident 3's limited mobility to his/her right hand and arm.
83.35(3)(c) Implement, follow the individual service plan: Staff did not implement Resident 3's individual service plan as written, failing to provide water in a cup with handles and assist with range of motion.
83.44(2)(a) Rooms clean and free from odors: The provider did not ensure all resident rooms were kept clean and free from odor, with observations of soiled linens, dirty laundry on floors, and odors in rooms.
Report Facts
Deficiencies identified: 5
Repeat deficiencies: 2
Revisit fee: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding discharge notices and care concerns. |
| Clinical Director B | Clinical Director | Provided documentation and interviews related to medication administration and care plans. |
| Person D | Case manager interviewed regarding Resident 2's discharge and care. | |
| Family Member C | Legal representative of Resident 1 interviewed regarding discharge notice. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 29, 2025
Visit Reason
A standard survey and complaint investigation were conducted to determine if Mountain Terrace Senior Living CBRF 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 along with a standard survey. The report does not specify substantiation status.
Findings
The Department issued a Statement of Deficiency (SOD #V2PA11) 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 applicable requirements within 45 days.
Report Facts
Inspection fee: 200
Compliance timeframe: 45
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: 34
Deficiencies: 2
Date: Aug 29, 2025
Visit Reason
Surveyor conducted 3 complaint investigations and a standard survey at Mountain Terrace Senior Living CBRF from 08/22/2025 to 08/29/2025.
Complaint Details
Three complaints were investigated: two were unsubstantiated and one was substantiated. The substantiated complaint involved unprofessional conduct by Activity Director C towards Resident 1 during hospital transport.
Findings
Two deficiencies were identified: one related to medication administration errors for Resident 2, and one related to unprofessional conduct by Activity Director C towards Resident 1. Two complaints were unsubstantiated and one was substantiated.
Deficiencies (2)
Provider did not ensure Resident 2 received medications as prescribed; Midodrine was administered on 4 occasions despite blood pressure readings indicating it should have been held.
Activity Director C engaged in unprofessional conduct and made undignified comments towards Resident 1 during a hospital transport, including inappropriate jokes, lighting a cigarette and blowing smoke at EMS staff, and inappropriate physical gestures.
Report Facts
Number of complaints investigated: 3
Number of deficiencies identified: 2
Occurrences medication administered incorrectly: 4
Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Director C | Activity Director | Named in unprofessional conduct and undignified comments towards Resident 1 during hospital transport. |
| Administrator A | Administrator | Interviewed regarding complaint and acknowledged findings. |
| Clinical Director B | Clinical Director | Interviewed regarding medication administration and acknowledged findings. |
| Caregiver D | Caregiver | Witnessed and reported on incident involving Activity Director C and Resident 1. |
| Caregiver E | Caregiver | Reported observations regarding Activity Director C and Resident 1. |
| EMS Staff A | EMS Staff | Reported observations of Activity Director C's conduct during Resident 1's hospital transport. |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Date: Jul 9, 2024
Visit Reason
Surveyors conducted a complaint investigation at Mountain Terrace Senior Living CBRF starting on 07/09/2024 with data collection continuing through 07/10/2024.
Complaint Details
Complaints were investigated and found to be unsubstantiated.
Findings
The complaints were unsubstantiated and no deficiencies were identified during the investigation.
Inspection Report
Follow-Up
Census: 33
Deficiencies: 0
Date: Mar 7, 2024
Visit Reason
A verification visit was conducted at Mountain Terrace Senior Living CBRF to review compliance and verify correction of previous deficiencies.
Findings
No deficiencies were identified during the verification visit. A $200 revisit fee is being assessed under statutory provisions.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 24, 2023
Visit Reason
A standard survey and complaint investigations were conducted to determine if Mountain Terrace Senior Living CBRF was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit included complaint investigations to determine compliance with applicable statutes and codes.
Findings
The Department issued a Statement of Deficiency (SOD #CTZQ11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply immediately with requirements to ensure proper care, supervision, and services for residents, including behavior management and environmental safety systems. A forfeiture of $1,000 was imposed for specific violations.
Deficiencies (1)
Failure to comply with requirements specified by Wis. Admin. Code § DHS 83.38(1)(b) related to providing sufficient supervision and care to residents.
Report Facts
Forfeiture amount: 1000
Forfeiture amount: 600
Forfeiture amount: 400
Forfeiture payment reduction: 650
Compliance timeframe: 45
Extension request timeframe: 10
Forfeiture payment timeframe: 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: 28
Deficiencies: 2
Date: Oct 24, 2023
Visit Reason
The survey was conducted on 10/18/2023 and 10/24/2023 including two complaint investigations and a standard survey at Mountain Terrace Senior Living CBRF.
Complaint Details
One complaint was substantiated regarding a resident eloping from the facility for approximately one hour without staff awareness. The complaint investigation included review of police reports, staff interviews, and resident incident records.
Findings
Two deficiencies were identified, including failure to ensure a safe environment for residents who wander and elope, and inadequate fire drill documentation. One complaint was substantiated and one was unsubstantiated.
Deficiencies (2)
The provider did not ensure a safe environment for residents that wander and elope, as staff failed to respond appropriately to door alarms, resulting in a resident eloping unnoticed for nearly an hour.
The provider did not ensure fire drill documentation included residents' evacuation times and the type of assistance needed, with missing documentation for drills simulating sleeping hours and evacuation details.
Report Facts
Deficiencies identified: 2
Staff signatures on in-service: 14
Fire drill frequency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Officer F | Police Officer | Responded to call about eloped resident and reported staff unawareness. |
| Caregiver I | Caregiver | Interviewed regarding door alarm response and resident elopement. |
| Caregiver J | Caregiver | Interviewed regarding door alarm response and resident elopement. |
| Executive Director A | Executive Director | Provided staffing information and fire drill documentation status. |
| Assistant Director B | Assistant Director | Assisted in fire drill documentation review. |
| Interim Executive Director C | Interim Executive Director | Assisted in fire drill documentation review. |
| Executive Director D | Executive Director | Assisted in fire drill documentation review and authored door alarm in-service note. |
| Executive Director E | Executive Director | Assisted in fire drill documentation review. |
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