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
10 residents
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Re-Inspection
Census: 10
Deficiencies: 0
Date: Sep 17, 2025
Visit Reason
The surveyor conducted two verification visits at Charter Senior Living of Hasmer Lake for Statement of Deficiency's (SOD) 81YW11 dated 06/24/2025 and SOD FVFI11 dated 02/04/2025. The multiple surveys were combined into one revisit survey.
Findings
No deficiencies were identified during this revisit survey. All previous citations were corrected. A $200 revisit fee is being assessed under statutory provisions.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 24, 2025
Visit Reason
A complaint investigation was conducted on June 24, 2025, for Charter Senior Living of Hasmer Lake to determine if the facility was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related and concluded that the facility was not in substantial compliance with applicable statutes and administrative codes. The Department issued enforcement actions including a forfeiture.
Findings
The Department of Health Services issued a Statement of Deficiency (SOD #81YW11) citing violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation, an Order to Comply, and an imposed forfeiture of $940.00.
Deficiencies (1)
Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #81YW11
Report Facts
Forfeiture amount: 940
Reduced forfeiture amount: 611
Days to comply: 45
Days to request extension: 10
Days to pay forfeiture: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 1
Date: Jun 24, 2025
Visit Reason
A complaint investigation was conducted from 06/19/2025 to 06/24/2025 at Charter Senior Living of Hasmer Lake following a complaint received on 02/14/2025 alleging concerns with administration of resident medications.
Complaint Details
The complaint was substantiated. The investigation was triggered by a complaint received on 02/14/2025 alleging concerns with medication administration for Resident 1.
Findings
One deficiency was identified and substantiated related to medication administration errors for Resident 1, including incorrect dosages of sliding scale insulin on 24 occasions and failure to hold Midodrine on 23 occasions despite parameters indicating to do so. The facility did not notify the physician when blood sugar was over 451, and the December 2024 MAR did not record sliding scale insulin units administered with breakfast and lunch.
Deficiencies (1)
Resident 1 received incorrect dosages of sliding scale insulin on 24 occasions between 09/01/2024 and 11/30/2024 and Midodrine was not held on 23 occasions when parameters indicated to hold the medication.
Report Facts
Medication administration errors: 47
Incorrect sliding scale insulin dosages: 24
Midodrine not held: 23
Census: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Clinician Specialist A | Interviewed and confirmed medication administration errors; reported no progress notes regarding sliding scale insulin. | |
| Executive Director B | Interviewed and acknowledged understanding of concerns; reported being new to role and unfamiliar with Resident 1. | |
| Memory Care Director C | Interviewed and acknowledged understanding of concerns; reported being new to role and unfamiliar with Resident 1. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 12, 2025
Visit Reason
A complaint investigation and self-report review were conducted to determine if Charter Senior Living of Hasmer Lake was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related and included a self-report review. The Department concluded the investigation on February 12, 2025, and found violations resulting in enforcement action.
Findings
The Department issued a Statement of Deficiency (SOD # FVFI11) for violations of Wisconsin Statutes and Administrative Code provisions related to the operation of the facility. A forfeiture of $700.00 was imposed for these violations.
Report Facts
Forfeiture amount: 700
Reduced forfeiture amount: 455
Forfeiture payment timeframe: 10
Compliance timeframe: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 14
Capacity: 24
Deficiencies: 4
Date: Feb 4, 2025
Visit Reason
An investigation into 5 complaints and a self-report was conducted at Charter Senior Living of Hasmer Lake CBRF on 02/04/2025 with information gathered through 02/12/2025.
Complaint Details
The investigation was triggered by 5 complaints and a self-report. Four of the five complaints were substantiated, including abuse allegations against a caregiver, failure to notify legal representatives of falls and injuries, inadequate supervision of a high fall risk resident, and elevator safety concerns.
Findings
Four of 5 complaints were substantiated. Deficiencies included failure to investigate and document abuse allegations, failure to immediately notify legal representatives of resident incidents and injuries, inadequate supervision leading to a resident lying on the floor for over seven hours, and lack of staff training and policy regarding elevator use causing safety risks.
Deficiencies (4)
Failure to investigate and document allegations of abuse or neglect and failure to ensure resident safety related to caregiver CG-D.
Failure to immediately notify residents' legal representatives of incidents and injuries, including multiple falls of Residents 4 and 6.
Failure to provide supervision appropriate to Resident 6's needs, resulting in Resident 6 lying on the bedroom floor for over seven hours without assistance.
Failure to ensure a safe living environment due to lack of staff training and policy on elevator use, resulting in residents being stuck and requiring fire department assistance.
Report Facts
Complaints investigated: 5
Complaints substantiated: 4
Resident census: 14
Total licensed capacity: 24
Resident falls: 12
Hours Resident 6 lay on floor: 7
Date of elevator inspection: Jan 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CG-D | Caregiver | Named in abuse allegations and subsequent termination. |
| Executive Director A | Executive Director | Interviewed regarding abuse investigations and incident notifications. |
| Operations Specialist B | Operations Specialist | Interviewed regarding abuse investigations and incident notifications. |
| Health and Wellness Director C | Health and Wellness Director | Mentioned in relation to abuse investigation and elevator incident. |
| Former Caregiver F | Caregiver | Failed to perform safety checks on Resident 6, resulting in termination. |
| Environmental Services Director J | Environmental Services Director | Provided information and demonstration about elevator operation. |
| Team Lead/Caregiver-K | Team Lead/Caregiver | Interviewed about elevator incident and lack of training. |
| Regional Director of Operations L | Regional Director of Operations | Interviewed regarding elevator training and policy. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 11, 2024
Visit Reason
A complaint investigation and verification visit were conducted on June 11, 2024, to determine if Charter Senior Living of Hasmer Lake was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, conducted to verify compliance with applicable statutes and codes. Specific substantiation status is not stated.
Findings
The Department issued a Statement of Deficiency (SOD #RT4K12) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, establishing grounds for regulatory action and requiring the licensee to comply with all requirements within 45 days.
Report Facts
Inspection fee: 200
Appeal filing timeframe: 10
Compliance timeframe: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 4
Date: Jun 11, 2024
Visit Reason
Surveyor conducted 2 complaint investigations and a verification visit at Charter Senior Living of Hasmer Lake, a CBRF in Jackson, focusing on allegations of injuries without explanation and failure to notify legal representatives.
Complaint Details
Two complaint investigations were conducted. One complaint was substantiated regarding failure to investigate injuries and notify legal representatives; one complaint was unsubstantiated.
Findings
Four deficiencies were identified, including failure to investigate injuries of unknown source, failure to notify legal representatives of incidents, failure to conduct quarterly psychotropic medication reassessments for 3 residents, and failure to maintain blood sugar records for 2 residents. One complaint was substantiated and one was unsubstantiated.
Deficiencies (4)
Failure to investigate an injury of unknown source for Resident 7 found with bruises on 03/07/2024.
Failure to immediately notify legal representatives of incidents or injuries for Resident 7 and Resident 4.
Failure to ensure 3 residents (Residents 1, 4, and 5) had quarterly reassessments for scheduled psychotropic medications within the past 90 days.
Failure to maintain documentation of blood sugar readings for Residents 1 and 6 each time monitored as ordered.
Report Facts
Revisit fee: 200
Deficiencies identified: 4
Residents reviewed for psychotropic reassessment: 3
Residents reviewed for blood sugar documentation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator D | Discussed concerns about notification failures and management transition. | |
| Clinical Specialist E | Interviewed regarding lack of injury investigation, psychotropic medication reassessments, and blood sugar documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 8, 2023
Visit Reason
A complaint investigation and standard survey were conducted to determine if Cedarhurst of Jackson was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related and included a complaint investigation. The Department found violations substantiated as detailed in SOD #RT4K11.
Findings
The Department issued a Statement of Deficiency (SOD #RT4K11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation, an Order to Comply, Special Orders, and a forfeiture of $700.
Report Facts
Forfeiture amount: 700
Reduced forfeiture amount: 455
Forfeiture amount by tag N389: 400
Forfeiture amount by tag N454: 300
Compliance timeframe: 45
Compliance notification timeframe: 7
Forfeiture payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 6
Date: Nov 8, 2023
Visit Reason
Surveyor conducted a complaint investigation and standard survey at Cedarhurst of Jackson, a CBRF in Jackson, to assess compliance with regulatory requirements and investigate a complaint.
Complaint Details
The complaint was unsubstantiated.
Findings
Six deficiencies were identified, including failure to update resident assessments after changes in condition, failure to update individual service plans, lack of quarterly reassessment of psychotropic medications, failure to document refusals of blood sugar monitoring and medication administration, lack of pet vaccination records, and improper handling of soiled laundry in food service areas. The complaint was unsubstantiated.
Deficiencies (6)
Provider did not ensure 2 of 3 residents reviewed were assessed when they had a change in condition; Resident 2 and Resident 3 did not have updated fall assessments.
Provider did not ensure 1 of 3 resident individual service plans was updated upon changes; Resident 2's ISP was not updated to include behavior of refusing cares.
Provider did not ensure 1 of 1 residents reviewed were reassessed quarterly for psychotropic medications; Resident 1's use of Citalopram and Quetiapine Fumarate was not reassessed quarterly.
Provider did not ensure the facility cat was vaccinated against diseases, including rabies.
Provider did not ensure refusals of blood sugar monitoring and medication administration were documented in 1 of 3 resident records reviewed; Resident 1's refusals and missed documentation occurred multiple times in October 2023.
Provider did not ensure soiled laundry was not transported in areas used for serving food; soiled laundry was observed in the 2nd floor dining room near residents eating lunch.
Report Facts
Deficiencies identified: 6
Repeat deficiencies: 2
Resident refusals documented: 13
Resident refusals documented: 55
Resident refusals documented: 2
Missed blood sugar documentation: 6
Missed medication administration documentation: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing B | Director of Nursing | Interviewed regarding Resident 2 and Resident 3's fall assessments, Resident 2's ISP, Resident 1's medication and blood sugar documentation, and laundry handling observations. |
| Regional Nurse C | Regional Nurse | Interviewed regarding Resident 2 and Resident 3's fall assessments, Resident 2's ISP, Resident 1's medication and blood sugar documentation, and pharmacy psychotropic medication reassessment. |
| Interim Administrator A | Interim Administrator | Interviewed regarding the facility cat vaccination records. |
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