Inspection Reports for Brookdale Madison West
429 S Yellowstone Dr, Madison, WI 53719, WI, 53719
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Nov 24, 2025
Visit Reason
Surveyors conducted a complaint investigation and a verification visit at Brookdale Madison West AL from 11/17/2025 to 11/24/2025.
Findings
No deficiencies were identified during the investigation. Four of the four deficiencies from a prior statement of deficiencies dated 08/19/2025 were substantially corrected. The complaint investigation was unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 19, 2025
Visit Reason
A complaint investigation and verification visit were conducted on August 19, 2025, at Brookdale Madison West AL to determine if the facility was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #XE2213) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A total forfeiture of $1000 was imposed for these violations, with specific fines of $600 and $400 for two cited codes. A $200 inspection fee was also assessed for a verification visit to confirm correction of prior violations.
Complaint Details
The visit was complaint-related, conducted to verify compliance following a complaint investigation. The Statement of Deficiency #XE2213 was issued based on findings from this complaint investigation.
Deficiencies (2)
| Description |
|---|
| Violation of Wis. Admin. Code 83.35(3)(d) |
| Violation of Wis. Admin. Code 83.48(3)(b) |
Report Facts
Forfeiture amount: 1000
Forfeiture amount: 600
Forfeiture amount: 400
Inspection fee: 200
Reduced forfeiture amount: 650
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: 54
Capacity: 74
Deficiencies: 4
Aug 19, 2025
Visit Reason
Surveyors conducted two complaint investigations and a verification visit at Brookdale Madison West AL following complaints about missing narcotic medication and refund delays.
Findings
Four deficiencies were identified including failure to report law enforcement involvement timely, delayed refund of entrance fees, failure to update individual service plans for behavioral changes, and lack of documentation for sensitivity testing. Two complaint investigations were substantiated.
Complaint Details
Two complaint investigations were substantiated: one regarding missing narcotic medication that was not reported to the department timely, and one regarding delayed refund of entrance fees.
Deficiencies (4)
| Description |
|---|
| Failure to report law enforcement being called to the facility within 3 working days after an incident involving missing narcotic medication. |
| Failure to refund the entire community fee within six months as required by the admission agreement; refund was issued over 90 days late. |
| Individual service plan was not updated to include behaviors of summoning police due to paranoia and wandering/elopement. |
| Lack of documentation of sensitivity testing as required by NFPA 72; sensitivity testing was scheduled but not completed as of the survey date. |
Report Facts
Revisit fee: 200
Community fee refund amount: 6110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director K | Executive Director | Interviewed regarding failure to report law enforcement involvement, refund delay, and ISP updates. |
| RN L | Registered Nurse | Interviewed regarding Resident 5's ISP and behavioral concerns. |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 7
Apr 16, 2025
Visit Reason
From 04/14/2025 to 04/16/2025, surveyors conducted 2 complaint investigations and a verification visit at Brookdale Madison West AL, a CBRF located in Madison, WI.
Findings
Seven deficiencies were identified, including three repeat violations. Five of seven deficiencies from a prior statement of deficiency were substantially corrected. Two complaint investigations were substantiated. A $200 revisit fee is being assessed under statutory provisions.
Complaint Details
Two complaint investigations were substantiated. The complaints involved failure to report incidents, inadequate employee training, medication administration errors, delayed treatment, failure to support resident autonomy, and inadequate health monitoring.
Deficiencies (7)
| Description |
|---|
| Provider did not report an incident/accident that occurred on 12/24/2024 resulting in Resident 4's hospital treatment and admission. |
| Provider did not ensure 2 of 2 employees reviewed obtained all department-approved training as required, including standard precautions, fire safety, first aid, choking, and medication administration training. |
| Caregiver H and Caregiver I did not have training in fire safety within 90 days after starting employment; repeat deficiency. |
| Provider did not ensure Resident 4 and Resident 1 received all prescribed medications in the dosage and at intervals prescribed by their practitioner; repeat deficiency. |
| Provider did not ensure residents received prompt and adequate treatment appropriate to their needs; Resident 1 had multiple call light wait times exceeding 60 minutes and delayed medication administration after emergency room visit. |
| Provider did not support Resident 1's autonomy after removing motorized wheelchair and did not ensure Resident 1 was supported in self-determination. |
| Provider did not assess or monitor Resident 4's injuries after falls, did not observe Resident 4's food and fluid intake or report significant changes in weight, and did not ensure documentation of sensitivity testing was maintained. |
Report Facts
Revisit fee: 200
Number of deficiencies identified: 7
Repeat deficiencies: 3
Call light wait times: 5
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director C | Executive Director | Interviewed regarding incident reporting, employee training, medication administration, call light response times, and sensitivity testing documentation |
| Res Care Coordinator J | Resident Care Coordinator | Interviewed regarding medication administration delays and new to position |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 18, 2024
Visit Reason
A standard survey and complaint investigation was conducted to determine if Brookdale Madison West 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 #XE2211) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a forfeiture order of $400.00 for noncompliance with regulatory requirements.
Complaint Details
The visit was complaint-related as it included a complaint investigation. Substantiation status is not explicitly stated.
Deficiencies (1)
| Description |
|---|
| Violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83 as identified in SOD #XE2211 |
Report Facts
Forfeiture amount: 400
Reduced forfeiture amount: 260
Forfeiture payment timeframe: 10
Compliance timeframe: 45
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: 57
Capacity: 74
Deficiencies: 7
Nov 18, 2024
Visit Reason
Surveyors conducted a complaint investigation and standard survey at Brookdale Madison West AL, a community-based residential facility (CBRF) in Madison, following an allegation of caregiver abuse.
Findings
Seven deficiencies were identified, including failure to take immediate steps to ensure resident safety after an abuse allegation, lack of documentation for heating system sensitivity testing, incomplete employee communicable disease screening and training, failure to complete quarterly psychotropic medication reviews, lack of weekly menus available to residents, and poor maintenance of interior floors and walls in a resident's room.
Complaint Details
The complaint was unsubstantiated. The investigation of the abuse allegation from 07/15/2024 concluded no substantiation of abuse, but the facility failed to take immediate safety measures during the investigation period.
Deficiencies (7)
| Description |
|---|
| Facility did not take immediate steps to ensure safety of all residents after an allegation of caregiver abuse on 07/15/2024. |
| Provider did not ensure documentation of heating system sensitivity testing was maintained. |
| Provider did not ensure 1 of 3 caregivers reviewed was screened for communicable disease including tuberculosis within 90 days before employment. |
| Caregiver A did not have training in fire safety within 90 days after starting employment; repeat deficiency. |
| Provider did not ensure Resident 3 was reassessed at least quarterly for desired responses and side effects of psychotropic medications. |
| Provider did not ensure a weekly menu was prepared and available to residents. |
| Provider did not ensure every interior floor and wall were clean and in good repair; Resident 1's bathroom had damaged drywall and stained flooring, and room carpeting had several stains. |
Report Facts
Deficiencies identified: 7
Census: 57
Total licensed capacity: 74
Caregiver E work hours: Worked 07/16/2024 from 3:07 p.m. to 9:46 p.m., 07/17/2024 from 2:58 p.m. to 10:57 p.m., and 07/19/2024 from 3:01 p.m. to 10:00 p.m.
Caregiver F work hours: Worked 07/16/2024 from 7:00 a.m. to 3:00 p.m., 07/16/2024 3:00 p.m. to 9:16 p.m., 07/18/2024 7:14 a.m. to 12:26 p.m., 07/18/2024 12:58 p.m. to 3:26 p.m., and 07/19/2024 7:20 a.m. to 2:01 p.m.
Psychotropic medication review dates: Reviews completed on 09/14/2023, 12/18/2023, and 06/17/2024; not quarterly as required.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver A | Not screened for communicable disease within 90 days before employment; did not complete fire safety training within 90 days. | |
| Caregiver E | Involved in abuse allegation investigation; worked during investigation period. | |
| Caregiver F | Involved in abuse allegation investigation; worked during investigation period. | |
| Executive Director II C | Executive Director | Interviewed regarding abuse allegation investigation, employee training, and psychotropic medication reviews; acknowledged deficiencies. |
| Business Office Manager D | Interviewed regarding employee records and training documentation. | |
| Nurse G | Nurse | Interviewed regarding Resident 2's report of being pushed by a caregiver. |
Report
File
XE2212ENFS.PDF_15533.pdf
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