Inspection Reports for Ameira Orchids Assisted Living
10401 W Bradley Rd. Milwaukee, WI 53224, United States, WI, 53224
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
47 residents
Based on a April 2025 inspection.
Census over time
Notice
Deficiencies: 0
May 5, 2025
Visit Reason
The document serves as a Notice of Violation and Order to Comply following five complaint investigations conducted to determine if Ameira Orchids Assisted Living 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, resulting in issuance of Statement of Deficiency #7DFW11 and an order for the licensee to achieve and maintain substantial compliance within 45 days.
Complaint Details
Five complaint investigations were concluded on May 5, 2025, leading to the issuance of the Statement of Deficiency #7DFW11 for violations found at the facility.
Report Facts
Compliance timeframe: 45
Inspection fee: 200
Appeal timeframe: 10
Posting duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MaryBeth Hoffman | 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: 47
Deficiencies: 4
Apr 17, 2025
Visit Reason
Surveyors conducted 5 complaint investigations at Ameira Orchids Assisted Living based on complaints received alleging residents did not always receive their prescribed medications and other care concerns.
Findings
Four complaints were substantiated and one was unsubstantiated. Four deficiencies were identified including failure to notify the department of administrator change, failure to ensure residents received medications as prescribed, incomplete individualized service plans, and inadequate documentation of insulin administration.
Complaint Details
Four complaints were substantiated and one complaint was unsubstantiated. Complaints included residents not always receiving prescribed medications and concerns about care delivery.
Deficiencies (4)
| Description |
|---|
| Provider did not notify the Department within 7 days of administrator change for 1 of 1 administrator (Administrator B). This was a repeat deficiency. |
| Provider did not ensure each resident received medication in accordance with physician's orders for 3 of 3 residents, resulting in missed doses of antibiotics, multiple sclerosis medications, and diabetes medications. |
| Provider did not ensure each resident had a comprehensive individualized service plan which identified methods for delivering needed care for 1 of 1 resident (Resident 2), resulting in verbal aggression and unmet care needs. |
| Provider did not ensure a system for documenting the dose of insulin given to 1 of 1 resident with a sliding scale, resulting in lack of documentation of insulin doses administered. |
Report Facts
Missed medication doses: 13
Number of complaints investigated: 5
Number of substantiated complaints: 4
Number of unsubstantiated complaints: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator B | Administrator | Named in deficiency for failure to notify department of administrator change and interviewed regarding medication and care issues. |
| Registered Nurse C | Registered Nurse | Confirmed lack of documentation system for insulin dosing and described use of Care Sheets and electronic record keeping. |
| Med Passer F | Mentioned in progress notes related to missed medication administration for Resident 1. | |
| Licensee A | Licensee | Interviewed regarding medication administration and plans to improve documentation and individualized service plans. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 6, 2025
Visit Reason
A verification visit and three complaint investigations were conducted to determine if Ameira Orchids Assisted Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #PBY613) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A forfeiture of $500 was imposed for these violations, with a reduced payment option of $325. Additionally, a $200 inspection fee was assessed for a revisit to verify correction of prior violations.
Complaint Details
The visit was complaint-related, involving three complaint investigations concluded on March 6, 2025. The report does not explicitly state substantiation status.
Report Facts
Forfeiture amount: 500
Reduced forfeiture amount: 325
Inspection fee: 200
Compliance timeframe: 45
Payment timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 2
Mar 6, 2025
Visit Reason
On 03/06/2025, a verification visit and 3 complaint investigations were conducted at Ameira Orchids Assisted Living. The visit was triggered by complaints regarding resident care and staff compliance.
Findings
Two deficiencies were identified: one involving the hiring of a caregiver under 18 without a waiver, and another involving denial of a resident's right to self-determination when Resident 13 was not allowed to return to the facility after a hospital visit due to lack of discharge information.
Complaint Details
Three complaints were investigated: two were substantiated and one was unsubstantiated. The substantiated complaints involved hiring underage staff without waiver and denial of resident's right to self-determination.
Deficiencies (2)
| Description |
|---|
| Provider did not ensure 1 of 4 staff members reviewed (Caregiver M) was 18 years old when hired; no waiver was requested from the Department. |
| Provider did not ensure Resident 13's right to self-determination; Resident 13 was denied access to his/her room after hospital discharge due to lack of discharge summary. |
Report Facts
Revisit fee: 200
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver M | Caregiver | Named in deficiency for being under 18 at time of hire |
| RN K | Registered Nurse | Named in incident report for refusing Resident 13's return without discharge summary |
| Quality Care Coordinator B | Quality Care Coordinator | Interviewed regarding Caregiver M's hiring and waiver status |
| Licensee A | Licensee | Interviewed regarding protocol for hospital discharges and Resident 13 incident |
| Care Coordinator H | Care Coordinator | Interviewed regarding Resident 13 incident |
| Enrichment Director J | Enrichment Director | Interviewed regarding Resident 13 incident |
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 1, 2024
Visit Reason
A verification visit and four complaint investigations were conducted to determine if Ameira Orchids Assisted Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #PBY612) for violations related to the administration and operation of the facility, including requirements to prevent foodborne illnesses through proper food handling, training, and menu planning. The licensee was ordered to comply immediately and maintain substantial compliance within 45 days.
Complaint Details
Four complaint investigations were concluded as part of the verification visit to assess compliance with applicable statutes and codes.
Deficiencies (3)
| Description |
|---|
| Failure to comply with requirements for safe food handling, including proper food storage, cleaning, and sanitizing the kitchen and appliances. |
| Lack of training for managers, food service workers, and caregivers regarding the facility’s written dietary procedures and measures to prevent foodborne illnesses. |
| Inadequate menu planning, food purchases, and inventory to ensure nutritious meals are available and resident food preferences are respected. |
Report Facts
Inspection fee: 200
Compliance timeframe: 45
Revisit fee timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter. |
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Oct 1, 2024
Visit Reason
Surveyors conducted a verification visit and 4 complaint investigations at Ameira Orchids Assisted Living. The visit was triggered by complaints and to verify compliance with reporting and food safety regulations.
Findings
Two deficiencies were identified, including a repeat violation. One deficiency involved failure to report a serious injury requiring hospitalization within 3 working days. The other deficiency involved improper food storage with unsealed and unlabeled food products in the freezer and refrigerator, posing a risk of food borne illness.
Complaint Details
Four complaints were investigated and found to be unsubstantiated. The visit included 4 complaint investigations and a verification visit.
Deficiencies (2)
| Description |
|---|
| Failure to notify the Department within 3 working days of a serious injury requiring hospitalization for Resident 12 after a fall on 05/31/2024. |
| Food was not stored under sanitary conditions; 7 of 7 opened food products in freezer and refrigerator were improperly sealed and labeled. |
Report Facts
Revisit fee: 200
Opened food products improperly sealed: 7
Fall date: May 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensee A | Interviewed regarding failure to report serious injury and food storage deficiencies; confirmed lack of awareness of reporting requirement and commitment to future compliance |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Jun 6, 2024
Visit Reason
Surveyor completed a complaint investigation at Ameira Orchids Assisted Living.
Findings
One complaint was unsubstantiated.
Complaint Details
One complaint was unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 2, 2024
Visit Reason
A standard survey and seven complaint investigations were conducted to determine if Ameira Orchids Assisted Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #PBY611) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a forfeiture order totaling $1,000 for multiple violations.
Complaint Details
Seven complaint investigations were concluded as part of the visit; substantiation status is not explicitly stated.
Report Facts
Forfeiture amount: 1000
Forfeiture amount: 600
Forfeiture amount: 200
Forfeiture amount: 200
Reduced forfeiture amount: 650
Compliance timeframe: 45
Payment timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter |
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
Inspection Report
Routine
Deficiencies: 11
Mar 29, 2024
Visit Reason
Surveyors conducted a standard survey and 7 complaint investigations at Ameira Orchids Assisted Living to assess compliance with regulatory requirements.
Findings
Thirteen deficiencies were identified including failure to report law enforcement calls timely, incomplete resident records, failure to notify administrator change, incomplete caregiver background checks, inadequate employee training, missing admission agreements, improper involuntary discharge notices, outdated service plans, incomplete PRN psychotropic medication documentation, unsafe food storage and handling, and lack of annual fire extinguisher inspections.
Complaint Details
Seven complaints were investigated; one was substantiated and six were unsubstantiated.
Deficiencies (11)
| Description |
|---|
| Failure to send a written report to the department within 3 working days after law enforcement personnel were called due to an incident jeopardizing health, safety, or welfare. |
| Resident records not maintained for 7 years following discharge; missing key documentation for Resident 1. |
| Failure to notify the department within 7 days of administrator change. |
| Caregiver background check not completed for 1 of 3 employees reviewed. |
| Employee training requirements not met for resident rights, client group training, challenging behaviors, dietary training, and continuing education. |
| Admission agreement not provided or signed before or at time of admission for 1 of 3 residents. |
| Involuntary discharge notice did not include required justification, department review statement, or contact information for department and ombudsman. |
| Individualized Service Plan not updated annually or on changes for 1 of 3 residents. |
| PRN psychotropic medication rationale and monthly monitoring documentation incomplete for 1 resident. |
| Food safety violations including uncovered, undated food items and hot food not maintained at 140°F or above prior to serving. |
| Fire extinguishers not inspected annually by qualified professional and not maintained in readily usable condition. |
Report Facts
Deficiencies identified: 13
Complaints investigated: 7
Complaints substantiated: 1
Complaints unsubstantiated: 6
PRN medication administrations: 15
Fire extinguishers: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator B | Administrator | Interviewed regarding reporting requirements, administrator change notification, missing resident records, training documentation, admission agreement, discharge notices, and PRN medication documentation. |
| Quality Care Coordinator H | Quality Care Coordinator | Interviewed regarding reporting requirements, caregiver background checks, training documentation, and PRN medication documentation. |
| Caregiver F | Caregiver | Did not have a completed caregiver background check on file. |
| Cook D | Cook | Did not have required resident rights, client group, challenging behaviors, dietary training, and was observed preparing food with unsafe food handling practices. |
| Resident Assistant E | Resident Assistant | Did not have required continuing education training in 2023. |
| DA I | Dietary Aide | Interviewed regarding food temperature and warming practices. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Sep 18, 2023
Visit Reason
Surveyor conducted 3 complaint investigations at Ameira Orchids Assisted Living.
Findings
No deficiencies were identified. Three complaints were unsubstantiated.
Complaint Details
Three complaints were investigated and found to be unsubstantiated.
Report Facts
Complaints investigated: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 26, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding Ameira Orchids Assisted Living to determine if the facility was in substantial compliance with Wisconsin Statutes and Administrative Code requirements for community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #S4DP11) for violations of Wisconsin Statutes and Administrative Code related to the operation of the facility, establishing grounds for regulatory action and requiring compliance within 45 days.
Complaint Details
Complaint investigation concluded on July 26, 2023, resulting in issuance of Statement of Deficiency #S4DP11 for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83.
Report Facts
Appeal filing timeframe: 10
Compliance timeframe: 45
Posting duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Beth Hoffman | 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: 44
Deficiencies: 1
Jul 26, 2023
Visit Reason
The surveyor completed a complaint investigation at Ameira Orchids Assisted Living following a complaint alleging a staff member was asleep on duty and became verbally abusive and physically aggressive towards a resident.
Findings
One deficiency was identified where the provider failed to report an allegation of abuse within 7 calendar days and did not take immediate steps to ensure the safety of all residents after learning of the incident involving a caregiver pushing a resident and being verbally abusive.
Complaint Details
One complaint was substantiated involving Caregiver D who was found sleeping on a sofa, became verbally abusive, and pushed Resident 1 on 06/28/2023. The provider delayed notification and investigation, with the Assistant Administrator arriving 2 hours after the incident and not reporting the abuse to the state within the required timeframe.
Deficiencies (1)
| Description |
|---|
| The provider did not ensure an allegation of abuse was reported within 7 calendar days to the department and did not take immediate steps to ensure the safety of all residents. |
Report Facts
Census: 44
Medication dosage: 10
Medication dosage: 20
Medication dosage: 0.25
Time elapsed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver D | Named in abuse allegation involving verbal abuse and physical pushing of Resident 1 | |
| Assistant Administrator B | Responsible for investigation and delayed response to abuse incident | |
| Administrator A | Interviewed and aware of reporting requirements to the state |
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