Inspection Report Summary
The most recent inspection on July 28, 2025, identified deficiencies related to medication administration and health monitoring, resulting in a $1,000 forfeiture and an order to comply. Earlier inspections showed a pattern of issues including employee communicable disease screening, resident assessments, psychotropic medication management, environmental cleanliness, and resident dignity, with some repeat deficiencies noted. Complaint investigations were unsubstantiated, and no license suspensions or additional enforcement actions were listed in the available reports. Prior enforcement included forfeitures totaling several hundred dollars and revisit fees, but no immediate jeopardy findings were reported. The facility’s record shows ongoing challenges with medication and health monitoring, with some improvement in complaint outcomes but persistent regulatory citations over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse 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 July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Deficiencies: 2
Date: Jul 28, 2025
Visit Reason
A standard survey was conducted to determine if Brookdale Sun Prairie was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #MZQ311) for violations related to medication administration and health monitoring, resulting in a Notice of Violation, Order to Comply, Special Orders, and a forfeiture of $1000.
Deficiencies (2)
Failure to ensure each resident's right to receive prescribed medications in the correct dosage and intervals.
Health monitoring deficiency identified in Statement of Deficiency MZQ311.
Report Facts
Forfeiture amount: 1000
Forfeiture amount (reduced): 650
Forfeiture breakdown: 200
Forfeiture breakdown: 500
Forfeiture breakdown: 300
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
Routine
Census: 13
Deficiencies: 8
Date: Jul 28, 2025
Visit Reason
A standard routine survey was conducted at Brookdale Sun Prairie, a Community Based Residential Facility (CBRF), to assess compliance with regulatory requirements.
Findings
Eight deficiencies were identified, including repeat deficiencies related to employee communicable disease screening, resident assessments after changes in condition, psychotropic medication reassessments, health monitoring, food safety, environmental cleanliness, and resident dignity and respect.
Deficiencies (8)
Failure to ensure 1 of 2 caregivers was screened for communicable disease including tuberculosis within 90 days before employment.
Failure to assess 1 of 3 residents for changes in needs after a fall.
Failure to reassess scheduled psychotropic medications quarterly by a pharmacist, practitioner, or registered nurse for 2 of 3 residents.
Failure to include rationale and detailed description of behaviors for PRN psychotropic medication use in individual service plans for 2 residents.
Failure to monitor and document blood pressure twice daily as ordered for 1 resident.
Freezer temperature was observed at 18°F and 31°F, exceeding the required 0°F or below.
Resident bathrooms were unclean with build-up around toilets; soiled laundry was on the floor; alarms were excessively loud and could cause fear.
Residents were not treated with full dignity and respect; one resident was assisted in the hallway wearing only a pajama top and depends; some residents waited over an hour for breakfast while others were served.
Report Facts
Deficiencies identified: 8
Repeat deficiencies: 3
Census: 13
Dates missing blood pressure readings: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Interviewed regarding deficiencies including tuberculosis test results, resident assessments, psychotropic medication reviews, health monitoring, food safety, environmental concerns, and resident dignity. | |
| Caregiver D | Caregiver | Not screened for tuberculosis within 90 days before employment. |
| Cook B | Cook | Reported freezer temperature issues and described alarm sounds. |
Inspection Report
Re-Inspection
Census: 12
Deficiencies: 0
Date: Aug 9, 2024
Visit Reason
Verification visit conducted to confirm correction of previously identified deficiencies.
Findings
No deficiencies were identified during the verification visit. The previously cited Statement of Deficiency dated 04/04/2024 was corrected.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 0
Date: Feb 2, 2024
Visit Reason
The visit was a verification visit and complaint investigation at Brookdale Sun Prairie, a CBRF in Sun Prairie.
Complaint Details
The complaint was investigated and found to be unsubstantiated. A $200 revisit fee was assessed under statutory provisions of Wis. Stat. Ch. 50.
Findings
No deficiencies were identified during the investigation. The previously cited Statement of Deficiency dated 09/06/2023 was corrected. The complaint was unsubstantiated.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 0
Date: Nov 28, 2023
Visit Reason
The visit was conducted as a complaint investigation and verification visit at Brookdale Sun Prairie, a Community-Based Residential Facility (CBRF).
Complaint Details
The complaint investigation resulted in zero violations being issued and confirmed correction of one prior violation. A $200 revisit fee was assessed under Wis. Stat. Ch. 50.
Findings
No violations of Chapter DHS 83 were issued as a result of the investigation. One violation from a previous statement of deficiencies dated 06/14/2023 was corrected.
Report Facts
Revisit fee: 200
Notice
Deficiencies: 0
Date: Sep 8, 2023
Visit Reason
A verification visit was conducted on September 8, 2023, to determine if Brookdale Sun Prairie 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 #YWN012 and imposition of a $300 forfeiture. A $200 revisit fee was also assessed for a follow-up inspection to verify correction of prior violations.
Report Facts
Forfeiture amount: 300
Reduced forfeiture amount: 195
Revisit 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
Re-Inspection
Census: 16
Deficiencies: 1
Date: Sep 6, 2023
Visit Reason
The surveyor conducted a verification visit to Brookdale Sun Prairie to assess compliance with communicable disease screening requirements for employees, specifically to verify correction of a previously cited deficiency.
Findings
One deficiency was identified related to failure to ensure that two caregivers were screened for communicable diseases, including tuberculosis, within 90 days prior to employment. This deficiency was a repeat from a prior survey dated 03/17/2023.
Deficiencies (1)
Failure to ensure 2 of 4 caregivers were screened for clinically apparent communicable disease, including tuberculosis, within 90 days before the start of employment.
Report Facts
Revisit fee: 200
Number of caregivers not screened: 2
Census: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver G | Caregiver | Named in deficiency for lack of communicable disease screening |
| Caregiver J | Caregiver | Named in deficiency for lack of communicable disease screening |
| Administrator I | Administrator | Interviewed regarding missing communicable disease screening documentation |
Notice
Deficiencies: 0
Date: Mar 17, 2023
Visit Reason
An abbreviated survey was conducted on March 17, 2023, to determine if Brookdale Sun Prairie 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 and an imposed forfeiture totaling $850.00. The licensee is ordered to comply with all requirements within 45 days.
Report Facts
Forfeiture amount: 850
Reduced forfeiture amount: 552.5
Forfeiture payment deadline: 10
Compliance timeframe: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen D. Lyons | Interim Assisted Living Director | Signed the notice letter. |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Abbreviated Survey
Census: 15
Deficiencies: 5
Date: Mar 15, 2023
Visit Reason
An abbreviated survey was conducted at Brookdale Sun Prairie, a Community-Based Residential Facility (CBRF), to assess compliance with regulatory requirements.
Findings
Five deficiencies were identified including failure to ensure employee communicable disease screening, inadequate continuing education for caregivers, failure to administer prescribed medication to a resident, inaccurate medication administration documentation, and unsafe, unclean, and uncomfortable environmental conditions.
Deficiencies (5)
Two caregivers were not screened for communicable disease, including tuberculosis, within 90 days before employment.
Two caregivers did not receive the required 15 hours of continuing education in 2022.
Resident 4 did not receive prescribed Latanoprost eye drops as ordered due to medication supply gaps.
Medication administration record inaccurately documented Resident 4's receipt of Latanoprost eye drops despite pharmacy delivery gaps.
Unsafe and unclean environment observed including broken toilets, feces on toilet seats, lack of toilet paper, and dusty registers.
Report Facts
Deficiencies identified: 5
Continuing education hours: 11
Census: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver G | Named in deficiencies for lack of communicable disease screening and insufficient continuing education; also interviewed regarding medication administration. | |
| Caregiver H | Named in deficiency for lack of communicable disease screening. | |
| Caregiver F | Named in deficiency for insufficient continuing education. | |
| Interim Executive Director A | Interim Executive Director | Interviewed regarding employee screening and environmental concerns. |
| Health and Wellness Director C | Health and Wellness Director | Interviewed regarding medication administration and environmental concerns. |
| Pharmacist E | Pharmacist | Interviewed regarding medication orders and pharmacy deliveries for Resident 4. |
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