Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
89% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
74% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 13, 2025
Visit Reason
A complaint investigation and verification visit was conducted on 06/13/2025 to determine if Brookdale Brookfield AL 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 related to medication management and administration, resulting in a Statement of Deficiency #Z21G17 and imposition of a forfeiture.
Complaint Details
The visit was complaint-related, conducted to investigate allegations and verify compliance. The report does not explicitly state substantiation status.
Deficiencies (1)
| Description |
|---|
| Failure to ensure each resident’s right to receive all prescribed medications in the dosage and at intervals prescribed by the practitioner. |
Report Facts
Forfeiture amount: 1200
Reduced forfeiture amount: 780
Revisit 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. |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 95
Deficiencies: 1
Jun 13, 2025
Visit Reason
The surveyor conducted one verification visit and one complaint investigation triggered by a medication error complaint received on 05/22/2025.
Findings
One deficiency was identified as a repeat violation related to medication administration errors involving residents 23, 24, and 25. The complaint was substantiated, and four of five prior deficiencies were substantially corrected.
Complaint Details
The complaint regarding a medication error was substantiated. Resident 23 received medications intended for another resident, was sent to the emergency room, admitted to ICU, and later transitioned to hospice care. Caregiver JJ administered medications meant for Resident 25 to Resident 23 and medications meant for Resident 23 to Resident 24. Caregiver KK was terminated and med training was conducted across the board.
Deficiencies (1)
| Description |
|---|
| Provider did not ensure residents received all prescribed medications in the correct dosage and intervals as prescribed by the practitioner for 3 of 4 residents reviewed. |
Report Facts
Revisit fee: 200
Deficiencies from prior SOD: 5
Residents served: 95
Census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver JJ | Named in medication error finding; administered wrong medications to residents. | |
| Caregiver KK | Named in medication error finding; terminated due to medication error. | |
| Assistant Executive Director Q | Assistant Executive Director | Interviewed regarding medication error and administration. |
| Health and Wellness Coordinator H | Health and Wellness Coordinator | Observed medication cart and eye drops related to deficiency. |
| Director of Clinical Services LL | Director of Clinical Services | Participated in discussion regarding medication errors. |
| Interim Executive Director MM | Interim Executive Director | Participated in discussion regarding medication errors. |
| Pharmacy Tech II | Pharmacy Technician II | Interviewed about medication dispensing and refills. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 7, 2025
Visit Reason
A complaint investigation and verification visit was conducted on January 7, 2025, to determine if Brookdale Brookfield AL was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #Z21G16) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A forfeiture of $1170.00 was imposed for these violations, with some forfeitures accruing daily until compliance is achieved. A $200 inspection fee was also assessed for a verification visit conducted on January 7, 2025, to determine if prior violations were corrected.
Complaint Details
The visit was complaint-related, conducted to verify compliance with applicable statutes and administrative codes. The Department found violations and issued a Statement of Deficiency.
Deficiencies (1)
| Description |
|---|
| Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #Z21G16 |
Report Facts
Forfeiture amount: 1170
Reduced forfeiture amount: 760.5
Inspection fee: 200
Compliance timeframe: 45
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
Complaint Investigation
Census: 65
Capacity: 95
Deficiencies: 5
Jan 7, 2025
Visit Reason
Surveyors conducted a verification visit, a complaint investigation, and a standard survey due to a complaint received regarding medications and other compliance concerns.
Findings
Five deficiencies were identified, including missing four-year caregiver background checks for two caregivers, failure to ensure residents received prescribed medications as ordered for three residents, improper disposal of expired medications, inaccurate medication administration documentation, and lack of semi-annual evacuation drills for 2023 and 2024.
Complaint Details
The complaint was substantiated. The complaint involved medication administration issues, including missed doses and discrepancies in medication availability and administration documentation.
Deficiencies (5)
| Description |
|---|
| Caregiver background checks for two caregivers were not conducted every four years as required. |
| Resident rights to receive all prescribed medications in the correct dosage and intervals were not ensured for three residents. |
| Expired medications were retained and not disposed of after 30 days past expiration for two residents. |
| Staff documented administration of medication that was not actually administered, specifically polyethylene glycol for Resident 19. |
| Semi-annual evacuation drills for 2023 and 2024 were not completed as required. |
Report Facts
Deficiencies identified: 5
Repeat deficiencies: 2
Revisit fee: 200
Resident census: 65
Total licensed capacity: 95
Medication doses documented: 269
Expired medication count: 2
Discrepancies in medication administration: 5
Missed eye drop doses: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Executive Director | Interviewed regarding missing four-year background checks and medication administration concerns. |
| Health and Wellness Director CC | Health and Wellness Director | Interviewed regarding medication administration, expired medications, and evacuation drills. |
| Med Tech DD | Medication Technician | Interviewed and observed during medication cart inspection related to polyethylene glycol administration. |
| Business Office Manager GG | Business Office Manager | Interviewed regarding missing four-year background checks. |
| Caregiver HH | Caregiver | Interviewed regarding medication reordering policy and medication availability issues. |
| Assistance Executive Director Q | Assistant Executive Director | Participated in discussion about medication administration documentation concerns. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 13, 2024
Visit Reason
A complaint investigation and verification visit was conducted on 08/13/2024 to determine if Brookdale Brookfield AL 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 a Statement of Deficiency (SOD #Z21G15) and enforcement actions including a forfeiture and an order to comply with requirements.
Complaint Details
The visit was complaint-related, conducted to verify compliance with applicable statutes and administrative codes. The Department issued a Statement of Deficiency (SOD #Z21G15) based on findings from the complaint investigation.
Report Facts
Forfeiture amount: 1000
Reduced forfeiture amount: 650
Forfeiture amount: 600
Forfeiture amount: 400
Inspection fee: 200
Compliance timeframe: 45
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
Complaint Investigation
Census: 68
Deficiencies: 2
Aug 7, 2024
Visit Reason
Surveyors conducted a verification visit and a complaint investigation on 08/07/2024. The visit was triggered by a complaint and included review of service plans and medication administration records.
Findings
Two deficiencies were identified, including a repeat deficiency related to the failure to update an individual service plan to include the use of adaptive equipment for transferring in and out of bed. Another deficiency involved inaccurate proof-of-use records for schedule II drugs. The complaint was unsubstantiated.
Complaint Details
The complaint was unsubstantiated.
Deficiencies (2)
| Description |
|---|
| Individual service plan was not updated for a resident to include use of adaptive equipment to aid in transferring in and out of bed. |
| Provider did not ensure proof-of-use records for schedule II drugs were maintained accurately with date, time, dose administered, remaining balance, and signature of administrator or designee auditing daily. |
Report Facts
Revisit fee: 200
Deficiencies identified: 2
Census: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Executive Director | Participated in exit conference and discussed findings related to service plan and medication documentation |
| Health and Wellness Director CC | Health and Wellness Director | Participated in exit conference and discussed findings related to service plan and medication documentation |
| Assistant Executive Director Q | Assistant Executive Director | Discussed concerns of proof of use record documentation |
| Health and Wellness Director C | Health and Wellness Director | Interviewed regarding staff writing page numbers from Individual Narcotic Count book |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 11, 2024
Visit Reason
A verification visit and two complaint investigations were conducted to determine if Brookdale Brookfield AL was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #Z21G14) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation, Order to Comply, Special Orders requiring corrective measures and staff training, and imposed forfeitures totaling $1,200.
Complaint Details
The visit was complaint-related, involving two complaint investigations and a verification visit to assess compliance with statutory and administrative requirements.
Deficiencies (1)
| Description |
|---|
| Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #Z21G14 |
Report Facts
Forfeiture amount: 1200
Reduced forfeiture amount: 780
Forfeiture amount: 800
Forfeiture amount: 400
Inspection fee: 200
Compliance timeframe: 45
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
Complaint Investigation
Census: 73
Capacity: 95
Deficiencies: 2
Apr 11, 2024
Visit Reason
On 04/04/2024, surveyor conducted 2 complaint investigations and 1 verification visit at Brookdale Brookfield AL due to concerns about call pendant wait times and resident care.
Findings
Two deficiencies were identified, both repeat violations related to inadequate prompt and adequate treatment as residents experienced excessive call pendant wait times. Both complaints were unsubstantiated. The facility is licensed as a Class CNA CBRF with capacity for 95 residents.
Complaint Details
Two complaints were investigated and found unsubstantiated. Both deficiencies were repeat violations. Five of five deficiencies from a prior Statement of Deficiency dated 11/13/2023 were substantially corrected.
Deficiencies (2)
| Description |
|---|
| Provider did not ensure the resident right to prompt treatment; four residents experienced call pendant wait times exceeding 20 minutes. |
| Failure to update individual service plans annually or when resident needs changed, including failure to update Resident 14's ISP regarding need for bed baths when unsafe to shower using a shower chair. |
Report Facts
Revisit fee: 200
Census: 73
Total capacity: 95
Call pendant events exceeding 20 minutes: 42
Call pendant events exceeding 20 minutes: 29
Call pendant events exceeding 20 minutes: 27
Call pendant events exceeding 20 minutes: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Executive Director | Discussed concerns of long call pendant wait times and call pendant alarm notification procedures |
| RN H | Registered Nurse | Discussed call pendant alarm notification and monitoring |
| Assistant Executive Director Q | Assistant Executive Director | Discussed call pendant alarm notification and monitoring |
| Director of Rehab BB | Director of Rehab | Interviewed regarding Resident 14's shower chair and care plan |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Jan 25, 2024
Visit Reason
Surveyor conducted a complaint investigation at Brookdale Brookfield AL on 01/25/2024.
Findings
No deficiencies were identified during the complaint investigation. The complaint was unsubstantiated.
Complaint Details
The complaint was unsubstantiated.
Report Facts
Census: 75
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 13, 2023
Visit Reason
A complaint investigation and verification visit was conducted on 11/13/2023 to determine if Brookdale Brookfield AL was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #Z21G13) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, requiring the licensee to develop and implement corrective measures to ensure proper care, health, safety, and rights of residents. A forfeiture of $1,000 was imposed for violations described in the SOD.
Complaint Details
The visit was complaint-related, conducted to verify compliance with applicable statutes and codes. The Department found violations and issued a Statement of Deficiency.
Deficiencies (1)
| Description |
|---|
| Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #Z21G13 |
Report Facts
Forfeiture amount: 1000
Reduced forfeiture amount: 650
Revisit inspection fee: 200
Compliance timeframe: 45
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
Complaint Investigation
Census: 72
Deficiencies: 5
Nov 13, 2023
Visit Reason
Surveyors conducted a verification visit and complaint investigation triggered by a complaint regarding failure to notify a resident's legal representative and physician of an incident involving choking and the Heimlich maneuver.
Findings
Five deficiencies were identified, including failure to notify the resident's legal representative and physician of an incident, incomplete medication administration records for multiple residents, lack of supervision and delegation for medication aides administering injectable medications, and combustible materials stored improperly near a furnace. The complaint was substantiated.
Complaint Details
The complaint was substantiated. It involved failure to notify the resident's legal representative and physician of a choking incident and Heimlich maneuver performed on Resident 13. The resident was not assessed or monitored appropriately after the incident, and family members had to repeatedly request checks and emergency transport. The resident subsequently passed away due to aspiration pneumonia.
Deficiencies (5)
| Description |
|---|
| Provider did not ensure the resident's legal representative and physician were notified when there was an incident to the resident involving choking and Heimlich maneuver. |
| Provider did not complete medication administration records for 4 out of 5 residents reviewed, missing documentation of name, dosage, date, and time of medication taken. |
| Provider did not ensure medication aides received supervision and registered nurse delegation for administration of injectable medication such as insulin. |
| Provider did not ensure services adequate to meet residents' needs in the area of health monitoring were provided or arranged. |
| Provider did not ensure combustible material was not placed within 3 feet of any furnace. |
Report Facts
Deficiencies identified: 5
Repeat deficiencies: 2
Revisit fee: 200
Census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Family Member U | Legal representative and agent for Resident 13, involved in notification and incident reporting. | |
| Caregiver S | Witnessed choking incident and Heimlich maneuver on Resident 13, did not report incident timely. | |
| Executive Director A | Executive Director | Interviewed regarding notification and delegation issues related to Resident 13. |
| Assistant Executive Director Q | Assistant Executive Director | Interviewed regarding notification and delegation issues related to Resident 13. |
| Former Wellness Director M | Former Wellness Director | Previously delegated insulin administration, no longer employed at time of survey. |
| Med Tech R | Medication Technician | Not currently delegated to administer insulin by corporate registered nurse. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 21, 2023
Visit Reason
A standard survey, complaint investigation, and verification visit was conducted to determine if Brookdale Brookfield AL was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #Z21G12) for violations related to medication storage and administration. The licensee was ordered to comply with requirements immediately and develop corrective measures within 45 days. A forfeiture of $1,120 was imposed for the violations, with a reduced payment option of $728. An inspection fee of $200 was also assessed for a verification visit confirming correction of prior deficiencies.
Complaint Details
The visit included a complaint investigation as part of the standard survey and verification visit to assess compliance with applicable statutes and administrative codes.
Deficiencies (1)
| Description |
|---|
| Medication storage and administration deficiencies identified in Statement of Deficiency Z21G12 |
Report Facts
Forfeiture amount: 1120
Reduced forfeiture amount: 728
Forfeiture amount: 620
Forfeiture amount: 500
Inspection fee: 200
Compliance timeframe: 45
Appeal timeframe: 10
Revisit fee 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: 65
Capacity: 95
Deficiencies: 6
Jun 14, 2023
Visit Reason
On 06/14/2023, surveyors conducted a standard survey, one verification visit, and one complaint investigation. The complaint was substantiated and related to medication administration and other care concerns.
Findings
Six deficiencies were identified including failure to ensure employees completed required training within 90 days, failure to ensure residents received prescribed medications as ordered, failure to implement individual service plans, medication storage issues, infection control lapses, and combustible materials stored improperly.
Complaint Details
The complaint was substantiated. It involved medication administration errors, failure to follow individual service plans, and infection control issues.
Deficiencies (6)
| Description |
|---|
| Provider did not ensure 3 out of 3 employees obtained all department approved training within 90 days after starting employment. |
| Provider did not ensure residents received all prescribed medications in the dosage and intervals prescribed by the practitioner. |
| Provider did not ensure individual service plans were implemented and followed as written. |
| Provider did not ensure medications were stored in a locked cabinet and in a secure manner. |
| Provider did not follow an infection control program based on current standards of practice; staff did not follow hand hygiene procedures following medication administration. |
| Provider did not ensure combustible materials were not placed within 3 feet of any furnace, boiler, water heater, fireplace or other similar equipment. |
Report Facts
Deficiencies identified: 6
Revisit fee: 200
Census: 65
Total licensed capacity: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Executive Director | Interviewed regarding fire safety training and medication administration issues |
| Caregiver I | Did not have fire safety training within 90 days of employment | |
| Med Tech G | Did not have fire safety training within 90 days; involved in medication administration deficiencies | |
| Med Tech J | Did not have fire safety training within 90 days | |
| Pharmacy Tech N | Interviewed about medication cycles and delivery | |
| Pharmacist O | Interviewed about medication delivery history | |
| Health and Wellness Director M | Health and Wellness Director | Interviewed about medication administration issues |
| Nurse H | Interviewed regarding medication administration and refills | |
| Maintenance F | Interviewed about combustible materials storage |
Inspection Report
Follow-Up
Census: 58
Deficiencies: 0
Feb 24, 2023
Visit Reason
The visit was a verification follow-up to confirm correction of one deficiency from a prior Statement of Deficiencies dated 06/24/2022.
Findings
No deficiencies were identified during this verification visit, and the previously cited deficiency was corrected. A $200 revisit fee is being assessed under statutory provisions.
Report Facts
Revisit fee: 200
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