Deficiencies (last 1 years)
Deficiencies (over 1 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
32 residents
Based on a September 2025 inspection.
Census over time
Inspection Report
Enforcement
Deficiencies: 1
Sep 17, 2025
Visit Reason
A verification visit was conducted on September 17, 2025, to determine if Grace Commons I 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 $760 was imposed, with a reduced payment option of $494 if not appealed. The operator was ordered to comply immediately and submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Violation related to medication management services as identified in Statement of Deficiency JUC912 under Wis. Admin. Code § DHS 89.23(2)(a)2.c. |
Report Facts
Forfeiture amount: 760
Reduced forfeiture amount: 494
Inspection fee: 200
Compliance timeframe: 45
Plan of Correction submission timeframe: 10
Appeal timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the enforcement notice letter |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Follow-Up
Census: 32
Deficiencies: 1
Sep 17, 2025
Visit Reason
The surveyor conducted a verification visit to Grace Commons I to assess compliance with previously identified deficiencies, including a repeat violation from the prior survey dated 04/08/2025.
Findings
One deficiency was identified related to insufficient nursing services, specifically failure to monitor tenant blood pressure in accordance with medication administration parameters. The provider did not ensure proper adherence to blood pressure medication hold parameters for two tenants, with multiple occurrences of medications administered or held incorrectly.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that tenant blood pressure was monitored in accordance with medication administration parameters, resulting in inappropriate administration or holding of blood pressure medications for two tenants. |
Report Facts
Revisit fee: 200
Occurrences medication administered within hold parameters: 6
Occurrences medication held outside hold parameters: 2
Occurrences medication administered within hold parameters: 13
Census: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager B | Nurse Manager | Interviewed by surveyor and acknowledged staff noncompliance with medication parameters; discussed prior inservice training and plans for further training and audits |
Inspection Report
Enforcement
Deficiencies: 0
Apr 8, 2025
Visit Reason
A standard survey was conducted on April 8, 2025, to determine if Grace Commons I was in substantial compliance with Wisconsin statutes and administrative codes governing residential care apartment complexes.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 89, resulting in a Statement of Deficiency #JUC911 and the imposition of a forfeiture.
Report Facts
Forfeiture amount: 240
Reduced forfeiture amount: 156
Forfeiture payment deadline days: 10
Compliance timeframe days: 45
Inspection fee amount: 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
Routine
Census: 31
Deficiencies: 1
Apr 8, 2025
Visit Reason
A standard survey was conducted at Grace Commons I to assess compliance with regulatory requirements for nursing services and medication administration.
Findings
One deficiency was identified related to the provider's failure to ensure Tenant 1's blood pressure was monitored correctly in accordance with medication administration parameters, resulting in multiple occurrences of medications being held or administered incorrectly based on systolic blood pressure readings.
Deficiencies (1)
| Description |
|---|
| Provider did not ensure Tenant 1's health was monitored in accordance with blood pressure monitoring parameters affecting administration of blood pressure medications lisinopril and metoprolol, with 9 occurrences of medication held incorrectly and 3 occurrences of medication administered despite hold parameters. |
Report Facts
Occurrences of medication held incorrectly: 9
Occurrences of medication administered incorrectly: 3
Census: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager B | Nurse Manager | Interviewed regarding concerns about staff not following Tenant 1's blood pressure medication parameters |
| Caregiver C | Caregiver | Interviewed and confirmed staff should monitor Tenant 1's blood pressure 3 times daily and agreed with findings of incorrect medication administration |
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