Inspection Reports for
Anitas Gardens of Brookfield
15665 W Lisbon Rd, Brookfield, WI, 53005
Back to Facility ProfileDeficiencies (last 1 years)
Deficiencies (over 1 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
183% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
50 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Follow-Up
Census: 50
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
The visit was a verification follow-up to assess correction of three deficiencies previously cited in a Statement of Deficiency dated 06/25/2025.
Findings
No deficiencies were identified during this verification visit. The three prior deficiencies were substantially corrected. A $200 revisit fee is being assessed, and the facility's probationary license can be converted to a regular license effective 09/01/2025.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
A complaint investigation and verification visit was conducted on 06/25/2025 to determine if Anitas Garden of Brookfield was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, involving a complaint investigation and verification visit to assess compliance with applicable statutes and administrative codes. The violations identified in SOD #OS1E12 formed the basis for enforcement actions including forfeiture and probationary licensing.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency (SOD) #OS1E12 and imposition of a probationary license. A total forfeiture of $1,200 was imposed for the violations, with a reduced forfeiture option of $780 if not appealed. Additionally, a $200 inspection fee was assessed for a verification visit on 06/25/2025 to confirm correction of prior deficiencies.
Report Facts
Forfeiture amount: 1200
Reduced forfeiture amount: 780
Forfeiture amount: 800
Forfeiture amount: 400
Inspection fee: 200
Appeal filing timeframe: 10
Probationary license expiration date: Aug 31, 2025
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: 47
Deficiencies: 3
Date: Jun 25, 2025
Visit Reason
On 06/25/2025, surveyors conducted one verification visit and one complaint investigation at Anita's Gardens of Brookfield due to concerns regarding medication management and individual service plan updates.
Complaint Details
The complaint was substantiated. The Department received a complaint on 06/20/2025 regarding medication management and code status concerns. Surveyors investigated and found issues with medication administration records, proof-of-use documentation, and resident code status handling.
Findings
Three deficiencies were identified, including a repeat violation related to individual service plans not being updated for changes in residents' needs. The complaint was substantiated, and issues with proof-of-use records for scheduled drugs and access to resident records were also found.
Deficiencies (3)
Provider did not ensure individual service plans (ISP) were updated when there was a change in a resident's needs, abilities or physical condition for 2 of 3 residents reviewed.
Provider did not ensure a proof-of-use record for schedule II drugs contained the date and time administered, resident's name, practitioner's name, dose, signature of person administering, and remaining balance, signed and dated daily by administrator or designee.
Provider did not ensure employees in charge on each work shift had a means to access resident records.
Report Facts
Deficiencies identified: 3
Repeat deficiencies: 1
Census: 47
Revisit fee: 200
Syringes counted: 15
Tablets counted: 56
Tablets documented dispensed: 60
Tablets documented dispensed: 20
Tablets counted: 3
Tablets counted: 4
Tablets counted: 57
Tablets counted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN K | Registered Nurse | Interviewed and escorted surveyors during medication cart audit; provided clinical information on residents; involved in narcotic counts and medication record reviews. |
| Caregiver U | Interviewed by surveyors regarding Resident 3's pain and condition; involved in narcotic count with Caregiver W. | |
| Lead Caregiver V | Interviewed by surveyors about Resident 3's pain behaviors. | |
| Caregiver W | Involved in narcotic counts and medication administration documentation; acknowledged forgetting to document medication administration. | |
| Executive Director A | Executive Director | Discussed findings with surveyors; documented medication replacement request; acknowledged issues with proof-of-use records and emergency packet labeling. |
| Regional Director T | Regional Director | Discussed findings with surveyors alongside Executive Director A and RN K. |
| Nurse Z | Nurse | Documented Resident 4's observation notes including statements about no longer wanting to live. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 20, 2025
Visit Reason
A standard survey and complaint investigation was conducted to determine if Anitas Gardens of Brookfield 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. The Department concluded the investigation on March 20, 2025, and found violations leading to enforcement actions including a Notice of Violation and forfeiture.
Findings
The Department issued a Notice of Violation and Statement of Deficiency (SOD #OS1E11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply immediately and achieve substantial compliance within 45 days. A forfeiture of $4,020 was imposed for specific violations, with a reduced payment option of $2,613 if not appealed.
Deficiencies (4)
Violation of DHS Code 83.12(2)
Violation of DHS Code 83.32(3)(h)
Violation of DHS Code 83.35(1)(a)
Violation of DHS Code 83.35(3)(d)
Report Facts
Forfeiture amount: 4020
Reduced forfeiture amount: 2613
Forfeiture breakdown: 800
Forfeiture breakdown: 520
Forfeiture breakdown: 2400
Forfeiture breakdown: 300
Compliance timeframe: 45
Probationary license expiration date: Aug 14, 2025
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: 37
Capacity: 70
Deficiencies: 6
Date: Feb 18, 2025
Visit Reason
The survey included a standard inspection and three complaint investigations at Anita's Gardens of Brookfield to assess compliance with regulations related to resident care, abuse investigations, and service plans.
Complaint Details
The visit included complaint investigations related to allegations of abuse and neglect involving Resident 1, which were found unsubstantiated in three complaints. The provider failed to investigate and report an incident involving possible abuse by a 1:1 outside caregiver.
Findings
Six deficiencies were identified including failure to investigate and report abuse, incomplete admission agreements, inadequate medication administration, lack of comprehensive assessments, failure to update individual service plans (ISP) with changes in resident condition, and insufficient documentation and rationale for PRN psychotropic medication use.
Deficiencies (6)
Failure to investigate and report an incident involving Resident 1 restrained with a gait belt resulting in injury.
Admission agreements were not signed by the resident's legal representative prior to or at admission.
Physician orders for antibiotic ointment were incorrectly transcribed on the medication administration record (MAR), resulting in missed scheduled treatments.
Lack of comprehensive pre-admission and ongoing assessments addressing cognition, mood, behaviors, falls, and skin integrity.
Individual service plan (ISP) was not updated to reflect changes in resident needs, including fall prevention interventions, back brace use, and Foley catheter management.
Resident's ISP did not include rationale or detailed description of behaviors indicating need for PRN psychotropic medication administration.
Report Facts
Deficiencies identified: 6
Census: 37
Total Capacity: 70
PRN quetiapine administrations: 6
Daily cost of 1:1 caregiver: 989
Falls documented: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Named in relation to failure to investigate abuse, lack of physician orders for restraint, and communication about Resident 1's incidents. | |
| RN B | Registered Nurse | Involved in care and assessments of Resident 1, acknowledged lack of wound assessment and ISP updates. |
| FLPN-C | Former Licensed Practical Nurse | Mentioned in relation to Resident 1's falls and behaviors. |
| Family Member P | Power of Attorney for Health Care | Legal representative of Resident 1, provided information on resident's condition and care. |
Viewing
Loading inspection reports...
