Deficiencies (last 2 years)
Deficiencies (over 2 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
20 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 20
Deficiencies: 0
Aug 28, 2025
Visit Reason
Surveyor conducted a verification visit at High Point Residence Germantown North, a Community-Based Residential Facility (CBRF) in Germantown, WI.
Findings
No deficiencies were identified during the verification visit.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 26, 2025
Visit Reason
A complaint investigation was conducted on February 26, 2025, to determine if High Point Residence Germantown North was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD # RYPZ11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation and an imposed forfeiture totaling $1,560.00.
Complaint Details
The complaint investigation concluded that the facility was not in substantial compliance with applicable statutes and administrative codes, leading to enforcement actions including a forfeiture.
Deficiencies (2)
| Description |
|---|
| Violation of DHS Code 83.32(3)(h) |
| Violation of DHS Code 83.35(3)(d) |
Report Facts
Forfeiture amount: 1560
Forfeiture amount: 1160
Forfeiture amount: 400
Reduced forfeiture amount: 1014
Compliance timeframe: 45
Payment timeframe: 10
Appeal 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: 16
Deficiencies: 2
Feb 26, 2025
Visit Reason
The survey was conducted on 02/26/2025 to investigate two complaints at High Point Residence Germantown North. One of the two complaints was substantiated, resulting in two deficiencies, including a repeat deficiency.
Findings
The provider failed to ensure that one resident received all prescribed medications in the correct dosage and intervals, with multiple documented instances of medications not being available or administered as ordered. Additionally, the provider did not update the individual service plan (ISP) annually or after a change in condition, specifically failing to revise the ISP after a physician ordered tubigrips for the resident.
Complaint Details
The complaint investigation was triggered by a complaint received on 12/19/2024 regarding medications not administered per physician's orders. One of two complaints was substantiated.
Deficiencies (2)
| Description |
|---|
| Provider did not ensure Resident 1 received all prescribed medications in the dosage and at intervals prescribed by a practitioner; this was a repeat deficiency. |
| Provider did not review and revise the individual service plan (ISP) annually or on change of condition for Resident 1, including failure to update the ISP after a physician ordered tubigrips. |
Report Facts
Deficiencies cited: 2
Medication hold codes documented: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Interviewed during survey and provided Resident 1's records. | |
| Executive Director B | Interviewed during survey, provided fax transmission status and Resident 1's notes, acknowledged lack of documentation for medication issues and ISP updates. | |
| Dr. C | Primary Care Physician | Ordered medications and tubigrips for Resident 1. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 1, 2024
Visit Reason
A complaint investigation and probationary survey was conducted to determine if Ellens Home of Germantown was in substantial compliance with Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, which govern community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #EWEE11) for violations of the applicable statutes and administrative codes, establishing grounds for regulatory action and an order to comply with requirements within 45 days.
Complaint Details
The visit was complaint-related and included a probationary survey. The Department found violations sufficient to issue a Statement of Deficiency and an order to comply.
Report Facts
Days to achieve compliance: 45
Appeal filing period: 10
Posting duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter as the Bureau of Assisted Living representative. |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 2
Mar 1, 2024
Visit Reason
Surveyor conducted a complaint investigation and probationary survey at Ellen's Home of Germantown. The complaint was unsubstantiated.
Findings
Two deficiencies were identified: 1) Resident 2 was given Midodrine medication despite blood pressure parameters indicating it should be held on 11 occasions, and 2) Resident 1 was not reassessed after a left avulsion fracture and change in mobility status from walker to wheelchair.
Complaint Details
The complaint was unsubstantiated.
Deficiencies (2)
| Description |
|---|
| Provider did not ensure Resident 2 received prescribed medications in the dosage and intervals prescribed; Midodrine was given when blood pressure was above parameters on 11 occasions. |
| Provider did not ensure an assessment of Resident 1's physical and mental condition was completed after a change in needs; no reassessment after left avulsion fracture and change in mobility. |
Report Facts
Medication administration discrepancies: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver D | Observed administering Resident 2's medications and stating medication holding procedures | |
| Director A | Acknowledged staff should have held Resident 2's Midodrine and confirmed no change of condition assessment for Resident 1 | |
| Administrator B | Acknowledged staff should have held Resident 2's Midodrine and acknowledged concern about Resident 1's lack of reassessment | |
| Director of Operations C | Acknowledged concerns and stated provider will implement electronic health records with built-in assessments |
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