Inspection Reports for
Copperstone Assisted Living
751 DEERWOOD, NEENAH, WI, 54956
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
107% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
59 residents
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Oct 4, 2024
Visit Reason
A complaint investigation was conducted to determine if Copperstone Assisted Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, concluding on October 4, 2024, but the substantiation status is not stated.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency (SOD #D4NU11) being issued to the facility.
Report Facts
Appeal timeframe: 10
Compliance timeframe: 45
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter as the Bureau of Assisted Living Director. |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Date: Sep 30, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by concerns that residents were required to continue payment past their 30-day discharge notice.
Complaint Details
Two complaint investigations were conducted; one of two complaints was substantiated regarding continued payment past the 30-day discharge notice.
Findings
One deficiency was identified related to the provider not returning an overpayment of $2,219.97 within 30 days of discharge for one resident. Resident 1 was charged additional rent fees and for a Wander Guard system not utilized after discharge.
Deficiencies (1)
Provider did not return an overpayment of $2,219.97 of resident funds within 30 days of discharge for Resident 1, who was charged additional rent fees and for a Wander Guard system not utilized after discharge.
Report Facts
Overpayment amount: 2219.97
Additional rent fees charged: 1881.2
Additional Wander Guard system fees charged: 338.77
Resident census: 59
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
A complaint investigation and self-report review was conducted on July 1, 2024, to determine if Copperstone Assisted Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, concluding a complaint investigation and self-report review. The Department found violations substantiating the complaint, as detailed in SOD #666611.
Findings
The Department issued a Statement of Deficiency (SOD #666611) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation and an imposed forfeiture of $300.00.
Report Facts
Forfeiture amount: 300
Reduced forfeiture amount: 195
Forfeiture payment timeframe: 10
Compliance timeframe: 45
Inspection fee: 200
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: 58
Deficiencies: 4
Date: Jul 1, 2024
Visit Reason
Surveyor conducted 3 complaint investigations and 3 self-report reviews at Copperstone Assisted Living, triggered by concerns including lack of 30-day notice for service fee changes and issues with admission agreements and health monitoring.
Complaint Details
Two of three complaints were substantiated. Complaints included lack of 30-day notice for service fee changes and concerns about cost and health monitoring delays.
Findings
Four deficiencies were identified including failure to provide 30-day written notice of service fee changes, incomplete admission agreements regarding additional fees, failure to update individual service plans for behavior changes, and inadequate health monitoring resulting in delayed treatment for a urinary tract infection.
Deficiencies (4)
Failure to provide a resident or their legal representative a 30-day written notice of a change in charge for services that would be in effect for more than 30 days.
Admission agreement did not include the rate being charged for services not covered under basic services, such as a WanderGuard.
Individual service plan was not updated to reflect a resident's aggressive behaviors.
Failure to ensure appropriate health monitoring; delayed urine sample collection and treatment for urinary tract infection.
Report Facts
Number of complaints investigated: 3
Number of self-report reviews: 3
Number of deficiencies identified: 4
Resident census: 58
WanderGuard monthly fee: 750
Delay in urine sample collection: 4
Delay in antibiotic treatment: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Interviewed regarding service fee notices, admission agreements, and health monitoring | |
| Licensed Practical Nurse B | Interviewed regarding service fee notices, admission agreements, individual service plans, and health monitoring |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Date: Dec 4, 2023
Visit Reason
A standard survey and complaint investigation was conducted at Copperstone Assisted Living on 12/04/2023 with additional information gathered through 12/05/2023.
Complaint Details
The complaint investigation was unsubstantiated with no deficiencies found.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the inspection.
Inspection Report
Follow-Up
Census: 57
Deficiencies: 0
Date: Jul 17, 2023
Visit Reason
Surveyor conducted a verification visit for Statement of Deficiency (SOD) GCTR11 and FPRQ11 at Copperstone Assisted Living in Neenah to verify correction of previous deficiencies.
Findings
All previous deficiencies were corrected, and no new deficiencies were identified during the visit.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
A complaint investigation was conducted to determine if Copperstone Assisted Living was in substantial compliance with Wisconsin Statutes and Administrative Code requirements for community-based residential facilities.
Complaint Details
The visit was complaint-related, concluding on March 14, 2023, with issuance of a Statement of Deficiency for violations found during the investigation.
Findings
The Department issued a Statement of Deficiency (SOD #GCTR11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, establishing grounds for enforcement action and requiring the licensee to comply with all applicable standards.
Report Facts
Compliance timeframe: 45
Inspection fee: 200
Appeal filing timeframe: 10
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen D. Lyons | Interim 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: 48
Deficiencies: 4
Date: Mar 8, 2023
Visit Reason
Surveyors conducted 3 complaint investigations on 03/08/2023 and returned on 03/14/2023 to investigate an additional complaint at Copperstone Assisted Living. The visit was triggered by allegations of inadequate staffing and medication administration issues.
Complaint Details
The visit was complaint-related, investigating allegations of inadequate staffing and medication errors. Two of four complaints were substantiated, including failure to provide adequate staffing and failure to administer medications properly.
Findings
Two of four complaints were substantiated, revealing insufficient staffing on a 24-hour basis and multiple residents not receiving their scheduled medications, including a hospice resident. Medication administration records showed numerous missed medications for several residents, and staff were not certified to pass medications. The facility failed to notify power of attorneys or doctors about the missed medications.
Deficiencies (4)
The provider did not ensure sufficient staff numbers on a 24-hour basis to meet resident needs.
Multiple residents did not receive their scheduled 8:00 AM and 12:00 PM medications as documented in medication administration records.
Med Passer was unable to pass medications within the required 2-hour window, and other staff were not certified to pass medications.
Power of attorneys and/or doctors were not notified about the missed medications for six residents.
Report Facts
Census: 48
Number of complaints investigated: 4
Number of complaints substantiated: 2
Number of residents with missed medications: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Memory Supervisor | Interviewed regarding staffing levels and medication administration | |
| Resident Coordinator | Interviewed regarding staffing and medication administration issues | |
| Administrator | Was on call during a staffing crisis but did not answer phone | |
| Med Passer | Unable to pass medications to all residents within the required time window |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Date: Feb 15, 2023
Visit Reason
Surveyor conducted a complaint investigation at Copperstone Assisted Living based on a complaint received.
Complaint Details
Complaint investigation was conducted and found to be unsubstantiated with no deficiencies identified.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 3, 2023
Visit Reason
A complaint investigation was conducted on February 3, 2023, to determine if Copperstone Assisted Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was a complaint investigation concluded on February 3, 2023, to assess compliance with relevant statutes and codes. The Department found violations and issued a Statement of Deficiency and imposed forfeiture.
Findings
The Department issued a Statement of Deficiency (SOD #FPRQ11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements to protect resident health, safety, and welfare, including monitoring residents' health and providing timely medical care. A forfeiture of $1,300 was imposed for specific violations.
Deficiencies (3)
Violation of Wis. Admin. Code § DHS 83.32(3)(h)
Violation of Wis. Admin. Code § DHS 83.35(1)(a)
Violation of Wis. Admin. Code § DHS 83.35(3)(d)
Report Facts
Forfeiture amount: 1300
Forfeiture amount: 600
Forfeiture amount: 300
Forfeiture amount: 400
Forfeiture payment deadline days: 10
Compliance deadline days: 45
Reduced forfeiture amount: 845
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen D. Lyons | Interim 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: 47
Deficiencies: 7
Date: Jan 18, 2023
Visit Reason
Surveyor conducted 3 complaint investigations at Copperstone Assisted Living related to medication administration, resident assessments, and care concerns.
Complaint Details
Three of three complaints were substantiated related to medication administration errors, inadequate assessments, and care deficiencies.
Findings
Seven deficiencies were identified including medication errors with residents not receiving medications as prescribed, lack of timely assessments following changes in condition, incomplete updates and signatures on individual service plans, inaccurate medication administration documentation, inadequate personal care assistance, insufficient health monitoring, and improper laundry handling.
Deficiencies (7)
Provider did not ensure 3 of 5 residents received medications as prescribed, including incorrect morphine dosing and missed doses due to pharmacy issues.
Provider did not ensure timely assessments following changes in condition for 3 residents after falls and pain reports.
Provider did not ensure 3 of 5 individual service plans were updated with changes in resident needs or signed by residents/legal representatives.
Provider did not accurately document medication administration for Resident 3's Augmentin and Resident 5's Lorazepam.
Provider did not ensure personal care was provided to allow residents to increase or maintain independence; Resident 1 did not receive assistance with tubigrips.
Provider did not ensure changes in residents' physical health were monitored and documented, including catheter site concerns and skin sores.
Provider did not ensure laundry was handled to prevent infection spread; soiled laundry was found on floors in resident rooms.
Report Facts
Deficiencies identified: 7
Missed medication doses: 6
Medication administration errors: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Named in multiple findings including medication errors, assessments, ISP updates, and follow-up documentation. | |
| Licensee C | Involved in follow-up discussions regarding medication administration and assessments. | |
| Pharmacist D | Pharmacist | Interviewed regarding medication orders and discrepancies. |
| Case Manager E | Case Manager | Interviewed regarding hospice medication orders for Resident 7. |
| Caregiver B | Caregiver | Interviewed about missing tubigrips and laundry handling. |
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