Inspection Reports for
Elizabeth Residence New Berlin
4461 S SUNNYSLOPE RD, NEW BERLIN, WI, 53151
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
74% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a October 2025 inspection.
Occupancy over time
Notice
Deficiencies: 0
Date: Oct 22, 2025
Visit Reason
A verification visit was conducted on 10/22/2025 to determine if Elizabeth Residence New Berlin 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 #OCR813 and imposition of a $300 forfeiture. The licensee is ordered to develop and implement corrective measures, including infection control training and procedures, within 45 days.
Report Facts
Forfeiture amount: 300
Forfeiture reduced amount: 195
Revisit inspection 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
Follow-Up
Census: 30
Capacity: 30
Deficiencies: 2
Date: Oct 22, 2025
Visit Reason
Surveyors conducted a verification visit at Elizabeth Residence New Berlin to assess correction of previously identified deficiencies.
Findings
Two deficiencies were identified, including one repeat violation related to infection control and handwashing practices. The provider did not ensure all staff followed infection control standards, particularly regarding cleaning and labeling of syringes and hand hygiene during medication passes.
Deficiencies (2)
Infection control program not properly followed; syringes used to flush Resident 14's feeding tube were not properly cleaned, dated, or replaced within 24 hours.
Hand washing procedures not followed; Caregiver O did not wash or sanitize hands between medication passes for Residents 15, 3, and 16.
Report Facts
Revisit fee: 200
Deficiencies identified: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver O | Named in infection control and handwashing deficiencies | |
| Nurse L | Named in infection control and handwashing deficiencies | |
| Administrator A | Administrator | Discussed infection control concerns and reeducation plans |
| Resident Manager M | Resident Manager | Discussed infection control concerns and reeducation plans |
Inspection Report
Follow-Up
Census: 28
Capacity: 30
Deficiencies: 2
Date: Jul 9, 2025
Visit Reason
On 07/08/2025, a surveyor conducted a verification visit at Elizabeth Residence New Berlin to assess correction of previously identified deficiencies.
Findings
Two deficiencies were identified as repeat violations related to residents not receiving medications as ordered. Staff failed to ensure accurate medication administration documentation and proper medication delivery for multiple residents. The facility is licensed as a CLASS CNA CBRF serving up to 30 residents with irreversible dementia/Alzheimer's and advanced age.
Deficiencies (2)
Provider did not ensure the resident right to receive medications as ordered by the physician for 5 of 7 residents reviewed.
Staff incorrectly documented medication administration, omitting units of sliding scale insulin for Resident 3.
Report Facts
Revisit fee: 200
Census: 28
Total capacity: 30
Medication administrations documented: 61
Medication administrations documented: 101
Medication administrations documented: 28
Medication administrations documented: 38
Medication administrations documented: 5
Medication administrations documented: 6
Medication administrations documented: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver J | Interviewed and observed during medication cart inspection | |
| Pharmacist K | Interviewed regarding medication deliveries and administration | |
| Nurse L | Nurse | Interviewed regarding sliding scale insulin administration and documentation |
| Administrator A | Administrator | Discussed medication administration concerns and staff retraining |
| Assistant Administrator M | Assistant Administrator | Participated in discussion of medication administration concerns |
| Caregiver N | Interviewed about medication documentation for Resident 3 |
Inspection Report
Enforcement
Deficiencies: 2
Date: Jul 8, 2025
Visit Reason
A verification visit was conducted on 07/08/2025 to determine if Elizabeth Residence New Berlin was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities (CBRF).
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency (SOD #OCR812) and imposed a total forfeiture of $1,670.00. A follow-up verification visit on 07/09/2025 assessed correction of prior violations and imposed a $200 inspection fee.
Deficiencies (2)
Violation of Wis. Admin. Code 83.32(3)(h)
Violation of Wis. Admin. Code 83.37(2)(d)
Report Facts
Forfeiture amount: 1670
Forfeiture amount: 1370
Forfeiture amount: 300
Reduced forfeiture amount: 1085.5
Inspection fee: 200
Days to achieve compliance: 45
Days to pay forfeiture: 10
Days to request hearing: 10
Days to pay revisit fee: 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
Complaint Investigation
Deficiencies: 0
Date: Feb 14, 2025
Visit Reason
A standard survey and a complaint investigation were conducted to determine if Elizabeth Residence New Berlin was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related as it included a complaint investigation concluded on 02/14/2025. The report does not explicitly state the substantiation status of the complaint.
Findings
The Department issued a Statement of Deficiency (SOD #OCR811) for violations of state statutes and administrative codes related to the administration and operation of the facility. The licensee was ordered to comply with requirements, including developing written procedures and staff training on medication management and administration. A forfeiture of $2,900 was imposed for the violations.
Report Facts
Forfeiture amount: 2900
Forfeiture amount: 1900
Forfeiture amount: 500
Forfeiture amount: 500
Days to achieve compliance: 45
Days to request extension: 10
Days to pay forfeiture: 10
Reduced forfeiture amount: 1885
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
Complaint Investigation
Census: 27
Capacity: 30
Deficiencies: 5
Date: Feb 14, 2025
Visit Reason
On 2025-01-31, with information gathered through 2025-02-14, a standard survey and one complaint investigation were conducted at Elizabeth Residence New Berlin.
Complaint Details
The complaint was unsubstantiated.
Findings
Five deficiencies were identified, including three repeat violations. The complaint was unsubstantiated. Deficiencies involved caregiver background checks, residents' rights to receive medication, and self-determination.
Deficiencies (5)
Licensee did not ensure a complete caregiver background check was conducted at time of hire and every 4 years after for 1 of 3 staff reviewed.
Provider did not ensure the resident right to receive medications as ordered by the physician. Seven of eight residents reviewed did not receive scheduled medications as ordered.
Provider did not ensure the resident's right to self-determination. Resident 8 verbally refused medication which was administered by staff.
Staff incorrectly documented physician ordered scheduled medication administration for 8 of 9 residents reviewed, including medications administered when not given and failure to document administration or reasons for not administering medications.
Provider did not ensure individual service plans were updated annually or when there was a change in condition or needs.
Report Facts
Deficiencies identified: 5
Repeat violations: 3
Census: 27
Total capacity: 30
Residents reviewed for medication: 8
Residents reviewed for documentation: 9
Incorrect doses administered: 20
Medication administration beyond timeframes: 33
Medication administration beyond timeframes: 40
Medication administration beyond timeframes: 372
Medication administration beyond timeframes: 191
Medication administration beyond timeframes: 450
Medication administration beyond timeframes: 363
Medication administration beyond timeframes: 145
Inspection Report
Follow-Up
Census: 26
Deficiencies: 0
Date: Apr 26, 2024
Visit Reason
Surveyor conducted a verification visit to Elizabeth Residence New Berlin to confirm correction of previously identified deficiencies.
Findings
No deficiencies were identified during this verification visit. Three of three deficiencies from a prior Statement of Deficiency dated 11/13/2024 were corrected.
Report Facts
Revisit fee: 200
Notice
Deficiencies: 0
Date: Nov 13, 2023
Visit Reason
A verification visit was conducted on 11/13/2023 to determine if Elizabeth Residence New Berlin 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 #OFRT13, imposition of a $2,200 forfeiture, and special orders requiring compliance with employee training and supervision standards.
Report Facts
Forfeiture amount: 2200
Reduced forfeiture amount: 1430
Forfeiture amount: 800
Forfeiture amount: 1000
Forfeiture amount: 400
Inspection fee: 200
Compliance timeframe: 45
Compliance timeframe: 10
Compliance timeframe: 7
Training timeframe: 90
Inspection Report
Follow-Up
Census: 30
Deficiencies: 3
Date: Nov 10, 2023
Visit Reason
Surveyor conducted a verification visit at Elizabeth Residence New Berlin to assess correction of previously identified deficiencies and compliance with department-approved training and medication administration requirements.
Findings
Three deficiencies were identified, including repeat violations related to staff training in fire safety, first aid, choking, and medication administration documentation. The provider did not ensure all employees completed required training or properly documented medication administration, posing risks for medication errors.
Deficiencies (3)
Failure to ensure 1 of 2 employees completed department-approved training in fire safety, first aid, and choking within 90 days of employment.
Failure to update individual service plans for changes in residents' needs, including use of contradictory 'Service Plan Task' forms instead of full ISPs.
Failure to document medication administration accurately, including number of units of sliding scale insulin administered, increasing risk of medication errors.
Report Facts
Deficiencies identified: 3
Uncorrected repeat violations: 2
Repeat violation: 1
Revisit fee: 200
Census: 30
Medication administrations not documented: 121
Medication administrations not documented: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide G | Dietary Aide | Named in deficiency for lack of training in fire safety, first aid, and choking within 90 days of employment |
| Resident Manager A | Resident Manager | Interviewed by surveyor; confirmed lack of training documentation and discussed medication administration concerns |
| RN B | Registered Nurse | Interviewed by surveyor; stated ISP updates may not show on printed forms but are in computer |
| Med Tech F | Medication Technician | Observed administering medication and noted documentation deficiencies |
Inspection Report
Deficiencies: 5
Date: Jun 29, 2023
Visit Reason
A verification visit was conducted on 06/29/2023 to determine if Elizabeth Residence New Berlin was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities (CBRF).
Findings
The Department issued a Statement of Deficiency (SOD #OFRT12) citing violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply immediately with requirements including developing comprehensive individual service plans and updating assessments. A total forfeiture of $2,730.00 was imposed for the violations.
Deficiencies (5)
Violation of Wis. Admin. Code § 83.20(2)(a)-(d)
Violation of Wis. Admin. Code § 83.32(3)(h)
Violation of Wis. Admin. Code § 83.35(3)(d)
Violation of Wis. Admin. Code § 83.37(1)(i)
Violation of Wis. Admin. Code § 83.47(2)(d)
Report Facts
Forfeiture amount: 2730
Reduced forfeiture amount: 1774.5
Forfeiture amount by tag: 1200
Forfeiture amount by tag: 280
Forfeiture amount by tag: 800
Forfeiture amount by tag: 150
Forfeiture amount by tag: 300
Inspection fee: 200
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
Follow-Up
Census: 27
Capacity: 30
Deficiencies: 5
Date: Jun 28, 2023
Visit Reason
The surveyor conducted a verification visit to assess correction of previously identified deficiencies and compliance with department-approved training, medication administration, service plan updates, and fire drills.
Findings
Five deficiencies were identified, all repeat violations from prior statements of deficiency. Deficiencies included lack of required employee training, medication administration errors, failure to update individual service plans, inadequate monitoring of psychotropic medication, and incomplete fire drill documentation.
Deficiencies (5)
Provider did not ensure 2 of 3 employees completed required department-approved training including fire safety and standard precautions.
Staff administered 7 incorrect doses of sliding scale insulin to Resident 11 from 05/12/2023 to 06/28/2023.
Individual service plans were not reviewed and revised when resident care needs changed for 2 of 2 residents reviewed.
Provider did not ensure monthly PRN psychotropic medication reviews were completed for Resident 13 for April 2023.
Fire drill documentation did not include total evacuation time or identification of residents with evacuation times greater than 4 minutes.
Report Facts
Deficiencies identified: 5
Revisit fee: 200
Census: 27
Total capacity: 30
Incorrect insulin doses: 7
Fire drill report date: Apr 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver C | Named in deficiency for lack of required training and fire safety training. | |
| Dietary Aide D | Named in deficiency for lack of required training including fire safety and standard precautions. | |
| Caregiver E | Included in training record review. | |
| Resident Manager A | Interviewed by surveyor regarding training and service plan concerns. | |
| Administrator G | Interviewed by surveyor regarding training, medication administration, and fire drill documentation. | |
| Caregiver G | Named in fire safety training deficiency. | |
| Caregiver H | Interviewed regarding Resident 9 wound care and mobility. | |
| Maintenance I | Interviewed regarding fire drill documentation and evacuation times. |
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