13 Reports
Inspection Report — Sep 24, 2025
Complaint Investigation State
Date: Sep 24, 2025
Visit Reason
Two complaint investigations were concluded for Willowick to determine if the facility was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
Two complaint investigations were concluded on 09/24/2025, resulting in findings of violations and issuance of SOD #JCO211.
Findings
The Department issued a Statement of Deficiency (SOD #JCO211) for violations of Wisconsin Statutes and Administrative Code provisions related to the operation of the facility, resulting in an imposed forfeiture of $500.
Report Facts
Forfeiture amount: 500
Reduced forfeiture amount: 325
Forfeiture payment timeframe: 10
Compliance timeframe: 45
Inspection fee: 200
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 — Sep 24, 2025
Complaint Investigation State
Date: Sep 24, 2025
Visit Reason
On 09/23/2025, the bureau of assisted living southern regional office conducted 2 complaint investigations at Willowick, a CBRF located in Beloit, WI.
Complaint Details
Two complaint investigations were conducted. One complaint was substantiated and one was unsubstantiated. The substantiated complaint involved failure to update Resident 1's individualized service plan after changes in condition and care needs.
Findings
As a result of the survey, 1 violation of DHS Chapter 83 was identified. One complaint was substantiated and one complaint was unsubstantiated. The provider failed to ensure Resident 1's individualized service plan (ISP) was reviewed and updated when there was a change in the resident's needs, abilities, or physical or mental condition.
Deficiencies (1)
83.35(3)(d) Service plans updated annually or on changes - Provider did not ensure Resident 1's individualized service plan was reviewed when there was a change in the resident's needs, abilities or physical or mental condition.
Report Facts
Medication administration days: 7
Medication administration dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Acknowledged Resident 1's diagnosis, antibiotic prescription, fall with injury, and plan for family to apply ACE bandage |
| Licensee B | Licensee | Acknowledged Resident 1's diagnosis, antibiotic prescription, fall with injury, and plan for family to apply ACE bandage |
| Practical Nurse C | Practical Nurse | Documented Resident 1's fall, medication administration, and care instructions; acknowledged diagnosis and care plans |
Inspection Report — Aug 27, 2025
Routine State
Date: Aug 27, 2025
Visit Reason
A standard survey was conducted on August 27, 2025, by the Division of Quality Assurance, Bureau of Assisted Living, to determine if Willowick was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #J8LR11) 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
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter as Bureau of Assisted Living, Division of Quality Assurance. |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report — Aug 27, 2025
Routine State
Date: Aug 27, 2025
Visit Reason
A standard survey was conducted at Willowick, a CBRF in Beloit, to assess compliance with regulatory requirements.
Findings
One deficiency was identified related to the failure to include the rationale for use and description of behaviors indicating the need for administration of PRN psychotropic medication in the Individual Service Plan (ISP) for one resident receiving Lorazepam .5 mg as needed.
Deficiencies (1)
The provider did not include the rationale for use and description of behaviors which indicate the need for administration of Lorazepam .5 mg in the Individual Service Plan of one resident receiving psychotropic medications as needed.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager A | Confirmed that the rationale for use and behavior description for Lorazepam .5 mg was not documented in the ISP. | |
| Executive Director B | Stated that Lorazepam will be added to the ISP. |
Inspection Report — Apr 23, 2025
Complaint Investigation State
Date: Apr 23, 2025
Visit Reason
The Bureau of Assisted Living conducted a complaint investigation and standard survey at Willowick, a Residential Care Apartment Complex (RCAC) in Janesville.
Complaint Details
The complaint was investigated and found to be unsubstantiated.
Findings
The survey resulted in no deficiencies and the complaint was unsubstantiated.
Inspection Report — Dec 16, 2024
Routine State
Date: Dec 16, 2024
Visit Reason
A standard survey and verification visit was conducted at Willowick from 12/11/2024 to 12/16/2024.
Findings
No deficiencies were identified during the survey. A previous deficiency from 04/04/2024 was substantially corrected.
Report Facts
Revisit fee: 200
Inspection Report — Apr 9, 2024
Complaint Investigation State
Date: Apr 9, 2024
Visit Reason
Surveyor conducted a complaint investigation at Willowick on 04/09/2024.
Complaint Details
The complaint was unsubstantiated.
Findings
No deficiencies were identified during the complaint investigation. The complaint was unsubstantiated.
Inspection Report — Apr 4, 2024
Enforcement State
Date: Apr 4, 2024
Visit Reason
A verification visit was conducted to determine if Willowick 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 #BXVC12 and imposition of a $400 forfeiture. The operator is ordered to comply with requirements and submit a Plan of Correction.
Report Facts
Forfeiture amount: 400
Reduced forfeiture amount: 260
Inspection fee: 200
Compliance timeframe: 45
Plan of Correction submission timeframe: 10
Forfeiture payment timeframe: 10
Appeal request timeframe: 10
Revisit fee payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the enforcement notice letter |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report — Apr 4, 2024
Re-Inspection State
Date: Apr 4, 2024
Visit Reason
The visit was a verification survey conducted to assess compliance with medication management and nursing services at the residential care apartment complex.
Findings
One deficiency was identified related to incomplete medication management documentation for two diabetic tenants. This deficiency was a repeat violation from a prior inspection.
Deficiencies (1)
89.23(2)(a)2.c SERVICES: The provider did not ensure complete medication management and administration for two tenants. Sliding scale insulin units and blood glucose levels were not recorded from 01/01/2024 to 04/03/2024.
Report Facts
Revisit fee: 200
Blood glucose levels recorded requiring sliding scale insulin: 229
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director A | Interviewed regarding concerns about diabetic management and documentation. | |
| Assistant Director B | Interviewed during the survey. | |
| Nurse C | Interviewed and acknowledged documentation issues; created EHR prompts for insulin recording. |
Inspection Report — Dec 20, 2023
Complaint Investigation State
Date: Dec 20, 2023
Visit Reason
Surveyor conducted a complaint investigation at Willowick on 12/20/2023.
Complaint Details
The complaint was unsubstantiated.
Findings
No deficiencies were identified during the complaint investigation. The complaint was unsubstantiated.
Inspection Report — Aug 11, 2023
Complaint Investigation State
Date: Aug 11, 2023
Visit Reason
The Bureau of Assisted Living, Southern Regional Office conducted a complaint investigation at Willowick, an RCAC in Janesville, WI.
Complaint Details
The complaint was investigated and found to be unsubstantiated with no violations issued.
Findings
The investigation resulted in zero violations of Chapter DHS 89. The complaint was unsubstantiated.
Report Facts
Violations: 0
Inspection Report — May 4, 2023
Complaint Investigation State
Date: May 4, 2023
Visit Reason
A standard survey and complaint investigation was conducted to determine if Willowick Assisted Living Beloit II LLC was in substantial compliance with Wisconsin Statutes Chapter 50 and Wisconsin Administrative Code Chapter DHS 83, which govern the administration and operation of 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 #8V5811) for violations of the applicable statutes and administrative codes, establishing grounds for regulatory action and an order to comply with requirements to protect resident health, safety, and welfare.
Report Facts
Appeal time frame: 10
Compliance time frame: 45
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen D. Lyons | Interim Assisted Living Director | Signed the notice letter. |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report — May 3, 2023
Complaint Investigation State
Date: May 3, 2023
Visit Reason
Surveyors conducted a complaint investigation and standard survey at Willowick on 05/04/2023. The complaint was unsubstantiated.
Complaint Details
The complaint was unsubstantiated.
Findings
One deficiency was identified related to the improper disposition of medications. The provider did not ensure that 4 of 4 resident medications were disposed of after 30 days of the expiration date, with expired medications stored alongside current medications for Residents 4, 5, 6, and 7.
Deficiencies (1)
Provider did not ensure 4 of 4 resident medications were disposed of after 30 days of the expiration date; expired medications were stored alongside current medications.
Report Facts
Expired medications: 8
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