Inspection Reports for High Point Residence Port Washington
1800 Granite Lane, Port Washington, WI, 53074
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 5, 2025, found no deficiencies and an unsubstantiated complaint. Earlier inspections showed a pattern of deficiencies related mainly to staff training, medication management, documentation, and maintaining a safe, clean living environment. Some substantiated complaints involved delayed staff responses, improper medication storage, incomplete service plans, and failure to report incidents timely. Enforcement actions included a $200 forfeiture and inspection fee in mid-2024, along with orders to comply following multiple citations, but no fines or license suspensions were noted in the available reports. The facility’s record shows improvement over time, with recent surveys indicating correction of prior issues and no new deficiencies identified.
Deficiencies (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
8
6
4
2
0
Census
Latest occupancy rate
38 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Abbreviated Survey
Census: 38
Deficiencies: 0
Date: Nov 5, 2025
Visit Reason
Surveyors conducted an abbreviated survey, one complaint investigation, and reviewed one self-report at High Point Residence Port Washington.
Complaint Details
One complaint was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated, one self-report was filed, and no deficiencies were identified during the survey.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Date: Jul 16, 2025
Visit Reason
The surveyor conducted two complaint investigations and a verification visit at High Point Residence Port Washington.
Complaint Details
Two complaints were investigated and found to be unsubstantiated.
Findings
Two complaints were unsubstantiated, previous deficiencies have been corrected, and no new deficiencies were identified.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 21, 2025
Visit Reason
A complaint investigation was conducted on January 21, 2025, to determine if High Point Residence Port Washington was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The complaint investigation was concluded on January 21, 2025, to assess compliance with Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. Violations were substantiated as evidenced by the issuance of Statement of Deficiency N6IY11.
Findings
The Department issued a Statement of Deficiency (SOD # N6IY11) 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 providing training to staff and implementing corrective measures.
Deficiencies (1)
Violations identified in Statement of Deficiency N6IY11 related to personal care services and compliance with statutory requirements.
Report Facts
Forfeiture amount: 1600
Reduced forfeiture amount: 1040
Forfeiture by tag: 800
Forfeiture by tag: 600
Forfeiture by tag: 200
Compliance timeframe: 45
Extension request timeframe: 10
Forfeiture payment timeframe: 10
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: 34
Capacity: 44
Deficiencies: 7
Date: Jan 15, 2025
Visit Reason
Surveyors conducted four complaint investigations at High Point Residence Port Washington due to complaints received regarding care, medication administration, and service plan updates.
Complaint Details
Three of four complaints were substantiated. Complaints included concerns about employee training, medication administration errors, inadequate service plan updates, medication storage and disposal, unsafe living environment, and delayed staff response to resident call lights.
Findings
The investigation substantiated 3 of 4 complaints, identifying 7 deficiencies including failure to ensure employee training compliance, medication administration errors, outdated individual service plans, improper medication storage, unsecured medications, and unsafe, unclean living environment conditions. Resident call light response times were also found to be excessively long.
Deficiencies (7)
Caregiver F did not have required training in fire safety and first aid and choking within 90 days of employment.
Resident 6 did not receive Levothyroxine medication as prescribed in dosage and timing.
Individual Service Plans for Residents 1 and 2 were not updated to reflect current needs including toileting assistance and smoking supervision.
Expired medications were not separated from current medications for 6 residents.
Medications for 19 residents were not securely stored; medication room was unlocked and medications were left unattended.
Living environment was not safe, clean, comfortable, or homelike, with obstructions in hallways, fecal matter in resident bathrooms, dirty vents, and stained carpets.
Resident call light response times frequently exceeded acceptable limits, with some responses delayed by several hours.
Report Facts
Number of complaints investigated: 4
Number of substantiated complaints: 3
Number of deficiencies identified: 7
Number of repeat deficiencies: 2
Facility licensed capacity: 44
Facility census: 34
Expired medications found: 6
Residents with unsecured medications: 19
Resident call light response times exceeding 20 minutes: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver F | Caregiver | Named in deficiency for lack of required fire safety and first aid/choking training. |
| Executive Director A | Executive Director | Interviewed regarding training records, medication administration, service plans, medication storage, and call light response times. |
| Caregiver D | Caregiver | Interviewed regarding medication administration, expired medications, and Resident 2 incident. |
| Caregiver E | Caregiver | Observed returning to medication cart during unsecured medication observation. |
| Caregiver C | Caregiver | Interviewed regarding cleaning schedules and resident room conditions. |
Inspection Report
Follow-Up
Census: 38
Deficiencies: 0
Date: Jul 18, 2024
Visit Reason
The surveyor conducted a verification visit to assess correction of previously identified deficiencies.
Findings
Three of three deficiencies were corrected and no new deficiencies were identified during the visit.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 2, 2024
Visit Reason
A complaint investigation and verification visit were conducted to determine if Ellens Home of Port Washington was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, involving a complaint investigation and verification visit to assess compliance with applicable statutes and administrative codes.
Findings
The Department issued a Notice of Violation and Statement of Deficiency (SOD #R6OQ12) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A forfeiture of $200 was imposed for violations identified, and a $200 inspection fee was assessed for a verification visit to determine if prior violations were corrected.
Deficiencies (1)
Violation of Wis. Admin. Code 83.29(2) as identified in SOD #R6OQ12
Report Facts
Forfeiture amount: 200
Reduced forfeiture amount: 130
Revisit inspection fee: 200
Forfeiture payment due days: 10
Appeal request deadline days: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice of Violation and Order letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 4
Date: Jun 20, 2024
Visit Reason
Surveyors investigated 3 complaints and conducted a verification visit at Ellens Home of Port Washington. The visit was triggered by complaints alleging incidents involving law enforcement intervention, admission agreement issues, individual service plan signatures, and medication administration documentation.
Complaint Details
Three complaints were investigated. One complaint involved failure to report law enforcement visits; another involved admission agreement signature issues; a third involved lack of legal representative signature on the individual service plan; and a fourth involved incomplete medication administration documentation. Three complaints were substantiated.
Findings
Three out of three complaints were substantiated resulting in three new deficiencies. Six of seven previous deficiencies were corrected. Deficiencies included failure to report law enforcement visits timely, admission agreement not signed by the activated power of attorney, individual service plan not signed by the legal representative, and incomplete medication administration documentation.
Deficiencies (4)
Provider did not report to the department within 3 working days after law enforcement personnel were called to the facility.
Provider did not ensure the legal representative signed and dated the admission agreement at the time of admission for Resident 1.
Provider did not ensure the resident's legal representative signed the individual support plan (ISP) acknowledging involvement, understanding, and agreement for Resident 1.
Provider did not ensure, at the time of medication administration, the person administering the medication initialed the medication record.
Report Facts
Revisit fee: 200
Census: 38
Medication administration missing initials: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Executive Director | Interviewed regarding law enforcement reporting, admission agreement signature, individual service plan signature, and medication administration documentation findings. |
Inspection Report
Enforcement
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
A probationary survey was conducted on March 13, 2024, to determine if Ellens Home of Port Washington was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department of Health Services issued a Statement of Deficiency (SOD #R6OQ11) 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 with Requirements to protect resident health, safety, and welfare.
Report Facts
Inspection fee: 200
Compliance timeframe: 45
Appeal timeframe: 10
Posting duration: 90
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
Original Licensing
Census: 37
Capacity: 44
Deficiencies: 6
Date: Mar 12, 2024
Visit Reason
A probationary survey was conducted at Ellens Home of Port Washington to assess compliance with licensing requirements and regulations.
Findings
Seven deficiencies were identified including failure to provide required employee orientation and training, lack of updated admission agreements for residents, failure to conduct required disaster evacuation drills semi-annually, hot water heaters not set to required temperature, and obstructed exit on the patio.
Deficiencies (6)
Failure to ensure prior to performing job duties, employees received required orientation training including job responsibilities, abuse prevention, emergency procedures, and recognizing resident condition changes.
Failure to ensure employees obtained all department-approved training including standard precautions, fire safety, first aid, medication administration, resident rights, client group training, and managing challenging behaviors within required timeframes.
Failure to have updated admission agreements for residents to provide information on services, charges, and terms after change of ownership.
Failure to conduct tornado, flooding, or other emergency evacuation drills at least semi-annually.
Failure to set hot water heaters connected to sinks, showers, and tubs used by residents to at least 140°F.
Failure to ensure patio exit was unobstructed; patio gate was chained and locked with a combination unknown to staff.
Report Facts
Deficiencies identified: 7
Census: 37
Total licensed capacity: 44
Water heater temperature: 136
Water temperature in resident rooms: 100
Water temperature in resident rooms: 96.8
New residents since license change: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver B | Named in deficiency for lack of orientation training prior to performing job duties. | |
| Caregiver C | Named in deficiencies for lack of orientation, department-approved training, and not being on the registry. | |
| Executive Director A | Executive Director | Interviewed regarding employee orientation, admission agreements, and emergency drills. |
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