Inspection Reports for Brookdale Brookfield Al

660 WOELFEL RD, WI, 53045-

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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/year

Deficiencies per year

8 6 4 2 0
2023
2024
2025

Census

Latest occupancy rate 74% occupied

Based on a June 2025 inspection.

Census over time

40 60 80 100 Feb 2023 Nov 2023 Apr 2024 Jan 2025 Jun 2025
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
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter.
Hillary HolmanAssisted Living Regional DirectorContact 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
NameTitleContext
Caregiver JJNamed in medication error finding; administered wrong medications to residents.
Caregiver KKNamed in medication error finding; terminated due to medication error.
Assistant Executive Director QAssistant Executive DirectorInterviewed regarding medication error and administration.
Health and Wellness Coordinator HHealth and Wellness CoordinatorObserved medication cart and eye drops related to deficiency.
Director of Clinical Services LLDirector of Clinical ServicesParticipated in discussion regarding medication errors.
Interim Executive Director MMInterim Executive DirectorParticipated in discussion regarding medication errors.
Pharmacy Tech IIPharmacy Technician IIInterviewed 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
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Hillary HolmanAssisted Living Regional DirectorContact 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
NameTitleContext
Executive Director AExecutive DirectorInterviewed regarding missing four-year background checks and medication administration concerns.
Health and Wellness Director CCHealth and Wellness DirectorInterviewed regarding medication administration, expired medications, and evacuation drills.
Med Tech DDMedication TechnicianInterviewed and observed during medication cart inspection related to polyethylene glycol administration.
Business Office Manager GGBusiness Office ManagerInterviewed regarding missing four-year background checks.
Caregiver HHCaregiverInterviewed regarding medication reordering policy and medication availability issues.
Assistance Executive Director QAssistant Executive DirectorParticipated 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
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Hillary HolmanAssisted Living Regional DirectorContact 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
NameTitleContext
Executive Director AExecutive DirectorParticipated in exit conference and discussed findings related to service plan and medication documentation
Health and Wellness Director CCHealth and Wellness DirectorParticipated in exit conference and discussed findings related to service plan and medication documentation
Assistant Executive Director QAssistant Executive DirectorDiscussed concerns of proof of use record documentation
Health and Wellness Director CHealth and Wellness DirectorInterviewed 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
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Hillary HolmanAssisted Living Regional DirectorContact 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
NameTitleContext
Executive Director AExecutive DirectorDiscussed concerns of long call pendant wait times and call pendant alarm notification procedures
RN HRegistered NurseDiscussed call pendant alarm notification and monitoring
Assistant Executive Director QAssistant Executive DirectorDiscussed call pendant alarm notification and monitoring
Director of Rehab BBDirector of RehabInterviewed 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
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Hillary HolmanAssisted Living Regional DirectorContact 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
NameTitleContext
Family Member ULegal representative and agent for Resident 13, involved in notification and incident reporting.
Caregiver SWitnessed choking incident and Heimlich maneuver on Resident 13, did not report incident timely.
Executive Director AExecutive DirectorInterviewed regarding notification and delegation issues related to Resident 13.
Assistant Executive Director QAssistant Executive DirectorInterviewed regarding notification and delegation issues related to Resident 13.
Former Wellness Director MFormer Wellness DirectorPreviously delegated insulin administration, no longer employed at time of survey.
Med Tech RMedication TechnicianNot 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
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Hillary HolmanAssisted Living Regional DirectorContact 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
NameTitleContext
Executive Director AExecutive DirectorInterviewed regarding fire safety training and medication administration issues
Caregiver IDid not have fire safety training within 90 days of employment
Med Tech GDid not have fire safety training within 90 days; involved in medication administration deficiencies
Med Tech JDid not have fire safety training within 90 days
Pharmacy Tech NInterviewed about medication cycles and delivery
Pharmacist OInterviewed about medication delivery history
Health and Wellness Director MHealth and Wellness DirectorInterviewed about medication administration issues
Nurse HInterviewed regarding medication administration and refills
Maintenance FInterviewed 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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