Inspection Reports for Brookdale Brookfield
685 Woelfel Road,Brookfield, WI, WI
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
13 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 13
Deficiencies: 0
Nov 24, 2025
Visit Reason
The Bureau of Assisted Living, Southern Regional Office conducted a verification visit of statement of deficiency (SOD) 1C3911 at Brookdale Brookfield Memory Care.
Findings
No citations of noncompliance were issued during this verification visit.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
May 9, 2025
Visit Reason
A standard survey and complaint investigation were conducted to determine if Brookdale Brookfield MC was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #1C3911) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation, Order to Comply, and an imposed forfeiture of $1600.00 for the identified violations.
Complaint Details
The visit was complaint-related and included a standard survey. The Department concluded the investigation with findings of violations as detailed in SOD #1C3911.
Report Facts
Forfeiture amount: 1600
Reduced forfeiture amount: 1040
Days to achieve compliance: 45
Days to request extension: 10
Days to pay forfeiture: 10
Days to file appeal: 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: 16
Deficiencies: 3
May 8, 2025
Visit Reason
The Bureau of Assisted Living conducted a standard licensing survey and complaint investigation at Brookdale Brookfield Memory Care on 05/08/2025 and 05/09/2025. The visit was triggered by a complaint, which was ultimately unsubstantiated.
Findings
The provider did not ensure that three residents received all prescribed medications in the dosage and at intervals prescribed by a practitioner. Specifically, Resident 1 did not receive polyethylene glycol as prescribed, Resident 2 did not receive Metamucil as prescribed, and Resident 3 did not receive eye medications as prescribed. Medication administration records and pharmacy deliveries showed discrepancies and incomplete administration of prescribed medications.
Complaint Details
The complaint was investigated and found to be unsubstantiated.
Deficiencies (3)
| Description |
|---|
| Resident 1 did not receive polyethylene glycol as prescribed. |
| Resident 2 did not receive Metamucil as prescribed. |
| Resident 3 did not receive eye medications as prescribed. |
Report Facts
Census: 16
Medication doses administered: 98
Medication doses on hold: 81
Medication doses administered: 354
Medication doses refused: 2
Medication doses not administered: 1
Medication doses administered: 798
Medication doses administered: 988
Medication doses administered: 184
Medication doses administered: 498
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| HWC C | Health and Wellness Coordinator/Licensed Practical Nurse | Named in medication administration findings and interviews regarding medication errors |
| Pharmacy Staff D | Provided pharmacy delivery and prescription information for residents' medications | |
| Assistant Administrator B | Provided resident records and communicated with surveyor | |
| HWD E | Health and Wellness Director/Registered Nurse | Documented alert charting note and participated in exit interview |
| Administrator A | Participated in exit interview discussing noncompliance |
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 0
May 14, 2024
Visit Reason
The Bureau of Assisted Living, Southern Regional Office conducted an onsite complaint investigation at Brookdale Brookfield Memory Care.
Findings
No citations of noncompliance were issued. The complaint was unsubstantiated.
Complaint Details
Complaint investigation was conducted and found to be unsubstantiated.
Inspection Report
Follow-Up
Census: 16
Deficiencies: 0
Nov 8, 2023
Visit Reason
Surveyors conducted a verification visit to confirm correction of a previously cited deficiency.
Findings
No deficiencies were identified during the verification visit. The previously cited violation #KD4U12 dated 07/21/2023 was corrected.
Report Facts
Revisit fee: 200
Inspection Report
Enforcement
Deficiencies: 1
Jul 21, 2023
Visit Reason
A verification visit was conducted on 07/21/2023 to determine if Brookdale Brookfield MC was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities (CBRF). The visit was to assess compliance and resulted in issuance of a Statement of Deficiency (SOD) #KD4U12.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83 at Brookdale Brookfield MC, leading to a Notice of Violation and an imposed forfeiture of $150.00. The licensee is ordered to comply with all requirements immediately and maintain substantial compliance within 45 days. A $200 inspection fee for a revisit to verify correction of prior violations was also assessed.
Deficiencies (1)
| Description |
|---|
| Violation of Wis. Admin. Code 83.46(1)(f) as identified in SOD #KD4U12 |
Report Facts
Forfeiture amount: 150
Reduced forfeiture amount: 97.5
Revisit inspection fee: 200
Compliance timeframe: 45
Appeal timeframe: 10
Forfeiture payment timeframe: 10
Revisit fee payment timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter |
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
Inspection Report
Follow-Up
Census: 17
Deficiencies: 1
Jul 21, 2023
Visit Reason
The surveyor conducted a verification visit at Liberty House 4 to follow up on previously identified deficiencies.
Findings
One deficiency was identified as a repeat violation related to combustible materials being placed within 3 feet of a furnace. Five of six violations from the prior inspection were corrected. The provider was not aware of the combustible materials rule but agreed to correct it.
Deficiencies (1)
| Description |
|---|
| Combustible materials were placed within 3 feet of a furnace, boiler, water heater, fireplace or other similar equipment, violating safety rules. |
Report Facts
Revisit fee: 200
Violations corrected: 5
Violations identified: 1
Census: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in observation and interview regarding combustible materials | |
| Maintenance F | Interviewed regarding combustible materials placement |
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 9, 2023
Visit Reason
A complaint investigation and abbreviated survey was conducted to determine if Brookdale Brookfield MC was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #KD4U11) for violations of state statutes and administrative codes, resulting in a Notice of Violation, an Order to Comply, and an imposed forfeiture totaling $700.00 for specific violations.
Complaint Details
The visit was complaint-related, conducted to investigate alleged noncompliance. The Department found violations and issued enforcement actions including forfeiture.
Deficiencies (2)
| Description |
|---|
| Violation of DHS Code 83.20 (2)(a)-(d) |
| Violation of DHS Code 83.35 (3)(d) |
Report Facts
Forfeiture amount: 700
Forfeiture amount: 400
Forfeiture amount: 300
Reduced forfeiture amount: 455
Compliance timeframe: 45
Payment timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter and enforcement |
| Kathleen D. Lyons | Interim Assisted Living Director | Signed the Notice and Order letter |
Inspection Report
Complaint Investigation
Census: 12
Capacity: 20
Deficiencies: 6
Mar 7, 2023
Visit Reason
Surveyors conducted a complaint investigation and an abbreviated survey at Brookdale Brookfield MC due to a complaint received regarding resident care and facility compliance.
Findings
Six deficiencies were identified including failure to notify the department when law enforcement was called, inadequate employee training in fire safety and first aid, failure to update resident service plans, improper medication administration, failure to perform hand hygiene, and combustible materials stored improperly near a furnace.
Complaint Details
The complaint was substantiated. Surveyors reviewed a police report and conducted interviews revealing failure to notify the department of law enforcement involvement and other compliance issues.
Deficiencies (6)
| Description |
|---|
| Failure to notify the Department when law enforcement was called to the facility after an incident jeopardizing resident or employee safety. |
| Provider did not ensure 1 of 2 employees completed department-approved training in standard precautions, fire safety, first aid, choking, and medication administration prior to assuming job duties. |
| Resident 4's individual service plan was not updated to reflect required crushed medications, assistance with mobility, and hospice services. |
| Caregiver B improperly administered crushed medications to residents without performing hand hygiene between residents and handled medication capsules with bare hands. |
| Provider did not ensure hand washing was performed according to CDC standards; caregiver did not wash hands between medication administrations. |
| Combustible materials were stored within 3 feet of a furnace, violating fire safety regulations. |
Report Facts
Deficiencies identified: 6
Licensed capacity: 20
Census: 12
Employees not trained: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver B | Named in findings related to improper medication administration and failure to perform hand hygiene. | |
| Caregiver C | Named in findings related to lack of required training in fire safety and first aid. | |
| Caregiver E | Interviewed regarding Resident 4's care needs and service plan. | |
| Executive Director A | Interviewed regarding notification requirements, training, and resident service plan deficiencies. | |
| Maintenance D | Interviewed regarding combustible materials stored near furnace. |
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