Inspection Reports for
Charter Senior Living of Madison

5601 Burke Rd, Madison, WI 53718, United States, WI, 53718

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 2.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

50% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/year

Deficiencies per year

8 6 4 2 0
2023
2024
2025

Census

Latest occupancy rate 51 residents

Based on a December 2025 inspection.

Occupancy over time

32 40 48 56 64 Apr 2023 Aug 2024 Apr 2025 Aug 2025 Dec 2025

Inspection Report

Follow-Up
Census: 51 Deficiencies: 0 Date: Dec 2, 2025

Visit Reason
Verification visit conducted to assess correction of a prior deficiency from a statement of deficiency dated 08/20/2025.

Findings
Zero deficiencies of Chapter DHS 89 were identified. One of one prior violation was substantially corrected. A $200 revisit fee is being assessed under statutory provisions.

Report Facts
Revisit fee: 200

Inspection Report

Enforcement
Deficiencies: 1 Date: Aug 20, 2025

Visit Reason
A verification visit was conducted on August 20, 2025, to determine if Charter Senior Living-Madison was in substantial compliance with Wisconsin statutes and administrative codes governing residential care apartment complexes (RCAC). This visit resulted in a Statement of Deficiency and enforcement actions.

Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 89 related to medication management and other operational requirements. A forfeiture of $400 was imposed, with a reduced payment option of $260 if not appealed. The operator is ordered to comply with corrective measures and submit a Plan of Correction within specified timeframes.

Deficiencies (1)
Violation related to medication management services as identified in Statement of Deficiency B33913.
Report Facts
Forfeiture amount: 400 Reduced forfeiture amount: 260 Forfeiture payment timeframe: 10 Plan of Correction submission timeframe: 10 Compliance timeframe: 45 Training timeframe: 45 Inspection fee amount: 200 Inspection fee payment timeframe: 10

Employees mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the enforcement notice and order.
Hillary HolmanAssisted Living Regional DirectorContact person for questions about the letter.

Inspection Report

Follow-Up
Census: 45 Deficiencies: 2 Date: Aug 20, 2025

Visit Reason
The surveyor conducted a verification visit to Charter Senior Living-Madison to assess compliance with Chapter DHS 89, focusing on medication management and nursing services.

Findings
The facility was found to have one repeat deficiency related to insufficient nursing services, specifically medication management. Two tenants did not receive proper medication administration: Tenant 1 did not receive the correct sliding scale insulin doses, and Tenant 3 missed scheduled topical pain medication on multiple occasions.

Deficiencies (2)
Failure to ensure Tenant 1 received the correct dose of sliding scale insulin as ordered.
Failure to administer scheduled topical pain medication (Biofreeze Gel) to Tenant 3 on 15 occasions due to medication not being available.
Report Facts
Revisit fee: 200 Missed medication administrations: 15 As needed acetaminophen doses: 13 Number of tenants reviewed: 2

Employees mentioned
NameTitleContext
FHealth and Wellness DirectorInterviewed regarding medication administration issues and pharmacy orders.
AExecutive DirectorInterviewed regarding medication administration issues and pharmacy orders.
DCaregiverInterviewed about medication cart and medication administration.
ECaregiverInterviewed about medication cart and medication administration.

Inspection Report

Complaint Investigation
Census: 43 Deficiencies: 1 Date: Apr 9, 2025

Visit Reason
Surveyors conducted a verification visit and a complaint investigation at Charter Senior Living-Madison on 04/09/2025.

Complaint Details
The complaint was unsubstantiated. One deficiency from a prior Statement of Deficiency dated 08/13/2024 was substantially corrected.
Findings
One deficiency related to medication management services was identified, involving incorrect insulin administration documentation for Tenant 1 and missed medication doses for Tenant 2. The complaint was unsubstantiated, and one prior deficiency was substantially corrected.

Deficiencies (1)
The provider did not ensure 2 of 4 tenants reviewed received medication management services; Tenant 1's insulin administration was not documented correctly, and Tenant 2 did not receive medications as prescribed.
Report Facts
Revisit fee: 200 Occurrences of incorrect insulin documentation: 38

Employees mentioned
NameTitleContext
Clinical Specialist BClinical SpecialistReviewed MARs, acknowledged documentation errors, and discussed medication concerns with surveyor and Executive Director.
Executive Director AExecutive DirectorAcknowledged documentation errors and medication administration concerns.
Caregiver ECaregiverConducted medication cart audit and explained medication dosing.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Apr 9, 2025

Visit Reason
A verification visit and complaint investigation were conducted on April 9, 2025, at Charter Senior Living-Madison to determine if the facility was in substantial compliance with Wisconsin statutes and administrative codes governing residential care apartment complexes.

Complaint Details
The visit was complaint-related and included a verification visit to determine compliance with applicable statutes and administrative codes. The complaint investigation concluded that violations existed, leading to the issuance of Statement of Deficiency #B33912.
Findings
The Department issued Statement of Deficiency #B33912 for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 89, including deficiencies related to medication management services. A forfeiture of $400 was imposed, with a reduced payment option of $260 if not appealed. The operator is ordered to comply with requirements and submit a Plan of Correction within specified timeframes.

Deficiencies (1)
Violation related to medication management services as identified in Statement of Deficiency B33912 under Wis. Admin. Code § DHS 89.23(2)(a)2.c.
Report Facts
Forfeiture amount: 400 Reduced forfeiture amount: 260 Days to achieve compliance: 45 Days to submit Plan of Correction: 10 Inspection fee: 200 Revisit fee: 200

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

Abbreviated Survey
Deficiencies: 0 Date: Aug 13, 2024

Visit Reason
An abbreviated survey was conducted on August 13, 2024, to determine if Charter Senior Living-Madison was in substantial compliance with Wisconsin Statutes chapter 50 and Administrative Code chapter DHS 89, which govern the operation of a residential care apartment complex (RCAC).

Findings
The Department issued a Statement of Deficiency (SOD) #B33911 for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 89, indicating noncompliance with regulatory requirements. The operator was ordered to comply immediately and submit a Plan of Correction within 10 days.

Report Facts
Compliance timeframe: 45 Plan of Correction submission timeframe: 10 Inspection fee: 200

Employees mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the notice letter
Hillary HolmanAssisted Living Regional DirectorContact person for questions about the letter

Inspection Report

Abbreviated Survey
Census: 37 Deficiencies: 2 Date: Aug 13, 2024

Visit Reason
Surveyors conducted an abbreviated survey at Charter Senior Living-Madison to assess compliance with regulatory requirements.

Findings
Two deficiencies were identified: incomplete medication management and administration for Tenant 1, and unsafe and unsanitary food storage conditions in the facility kitchen.

Deficiencies (2)
Incomplete medication management and administration for Tenant 1, including unavailable medications for Levothyroxine and Methenamine on multiple dates and failure to administer scheduled bedtime medications and blood sugar checks.
Food items in the freezer and cooler were improperly stored, including frost and ice buildup, uncovered food trays, items stored on the floor, and a broken freezer door seal.
Report Facts
Census: 37 Medication unavailability dates: 5 Medication unavailability dates: 2 Uncovered bacon pieces: 36

Employees mentioned
NameTitleContext
BDirector of NursingInterviewed regarding medication management deficiencies and medication cart observations
CEnvironmental Services DirectorInterviewed about kitchen conditions and freezer repair
AExecutive DirectorInterviewed during exit conference regarding medication and kitchen deficiencies

Inspection Report

Complaint Investigation
Census: 56 Deficiencies: 0 Date: Apr 28, 2023

Visit Reason
Surveyor conducted a complaint investigation at Cedarhurst of Madison on 04/28/2023.

Complaint Details
Complaint unsubstantiated.
Findings
No deficiencies were identified during the complaint investigation. The complaint was unsubstantiated.

Report Facts
Census: 56

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