Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
15 residents
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 29, 2025
Visit Reason
A complaint investigation was conducted on May 29, 2025, to determine if Cudahy Place was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, concluding on May 29, 2025, with issuance of a Statement of Deficiency. Specific substantiation status is not stated.
Findings
The Department issued a Statement of Deficiency (SOD #3GKE11) 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
Appeal timeframe: 10
Compliance timeframe: 45
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter |
| Mary Beth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 1
Date: May 29, 2025
Visit Reason
The inspection was conducted to conclude complaint investigations at Cudahy Place, specifically regarding concerns that the corporate office withdrew funds via electronic banking after a resident had moved out.
Complaint Details
One complaint was substantiated regarding the corporate office withdrawing funds via electronic banking after the resident had moved out. The complaint was received on 04/04/2024 and substantiated by the survey on 05/29/2025.
Findings
One deficiency was identified related to the provider not ensuring that a resident's remaining funds were disbursed to the resident's legal representative within 14 days after discharge. The provider withdrew $7,084 from the resident's account after the move-out date and refunded the amount two months later after intervention.
Deficiencies (1)
Provider did not ensure resident's funds were disbursed within 14 days after discharge; electronic withdrawal of $7,084 occurred after move-out date.
Report Facts
Refund amount: 7084
Timeframe for refund: 14
Timeframe for resolution: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator C | Administrator | Interviewed regarding the refund issue and email communications with accounts receivable. |
| Accounts Receivable Analyst G | Accounts Receivable Analyst | Communicated about the pending refund and resolution process. |
| Revenue Cycle Director D | Revenue Cycle Director | Sent email confirming refund check was cut and ready to be mailed. |
| Licensee F | Licensee | Acknowledged the ACH withdrawal error and mailed refund check. |
| Attorney E | Attorney | Involved in communications regarding the refund issue. |
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 0
Date: Mar 21, 2025
Visit Reason
The surveyor conducted complaint investigations at Cudahy Place.
Complaint Details
Two complaints were investigated and found to be unsubstantiated.
Findings
No deficiencies were identified and two complaints were unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 21, 2025
Visit Reason
A complaint investigation was conducted on January 21, 2025, to determine if Cudahy Place was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The complaint investigation concluded that the facility was not in substantial compliance with applicable statutes and administrative codes, leading to issuance of a Statement of Deficiency and enforcement actions.
Findings
The Department issued a Statement of Deficiency (SOD #QXMN11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation and an Order to Comply. The licensee was ordered to implement corrective measures and provide staff training within 45 days.
Deficiencies (1)
Failure to provide proper supervision to ensure residents receive proper care and treatment, protecting their health, safety, and rights.
Report Facts
Forfeiture amount: 1800
Reduced forfeiture amount: 1170
Forfeiture amount: 600
Forfeiture amount: 1200
Compliance timeframe: 45
Payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter. |
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter. |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 2
Date: Jan 21, 2025
Visit Reason
Surveyor completed a complaint investigation at Cudahy Place due to concerns about resident supervision and service plan updates.
Complaint Details
The complaint was substantiated. It involved concerns about resident supervision and failure to update service plans. Resident 1 and Resident 2 eloped from the facility on 08/25/2024. The facility had a repeat deficiency for supervision. The door alarm did not sound properly and staff did not respond timely. Family member had to intervene.
Findings
Two deficiencies were identified related to failure to update individual service plans to reflect residents' changing needs and inadequate supervision resulting in two residents eloping from the facility. The complaint was substantiated and this was a repeat deficiency.
Deficiencies (2)
Provider did not ensure each resident's individual service plan was updated when there was a change in resident's needs, abilities or physical or mental condition for 1 of 2 residents (Resident 1).
Provider did not ensure appropriate supervision for 2 of 2 residents (Resident 1 and Resident 2) who eloped from the facility and were returned by a family member.
Report Facts
Deficiencies identified: 2
Census: 18
Elopement incident time: 1630
Alarm reset time: 1639
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 0
Date: Mar 8, 2024
Visit Reason
Surveyor conducted a complaint investigation, standard survey, and verification visit at Cudahy Place.
Complaint Details
The complaint was unsubstantiated.
Findings
The previous deficiency was corrected and no new deficiencies were identified. The complaint was unsubstantiated.
Report Facts
Revisit fee: 200
Notice
Deficiencies: 0
Date: May 26, 2023
Visit Reason
Two complaint investigations were concluded on May 26, 2023, to determine if Cudahy Place was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
Two complaint investigations were concluded on May 26, 2023, for Cudahy Place. The report does not specify substantiation status.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency (SOD #974N11) and an imposed forfeiture of $800.00.
Report Facts
Forfeiture amount: 800
Reduced forfeiture amount: 520
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. |
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 1
Date: May 26, 2023
Visit Reason
The inspection was conducted to conclude two complaint investigations at Cudahy Place related to resident safety and supervision.
Complaint Details
Two complaints were received alleging a resident eloped from the facility during the night shift and staff were unaware until the police found the resident. Both complaints were substantiated.
Findings
The surveyor identified one deficient practice involving inadequate supervision of a resident who eloped from the facility, resulting in injury. Two complaints were substantiated, and the facility failed to follow established policies and procedures to prevent elopement.
Deficiencies (1)
The provider did not ensure appropriate supervision for 1 of 1 resident who eloped from the facility and suffered injury.
Report Facts
Census: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver B | Named in the finding for failing to provide supervision and resetting the alarm allowing resident elopement; terminated from employment. | |
| Caregiver C | Named as another caregiver present during the elopement who did not follow protocols. | |
| Administrator A | Administrator | Interviewed regarding policies, staff training, and incident details. |
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