Inspection Reports for Home Harbor Assisted Living Community

WI

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 2.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

41% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/year

Deficiencies per year

4 3 2 1 0
2023
2024
2025

Census

Latest occupancy rate 86 residents

Based on a September 2025 inspection.

This facility has shown a decline in demand based on occupancy rates.

Census over time

70 80 90 100 110 120 Mar 2023 Sep 2023 Sep 2024 Apr 2025 Sep 2025
Inspection Report Complaint Investigation Deficiencies: 0 Sep 25, 2025
Visit Reason
A complaint investigation and verification visit was conducted to determine if Home Harbor was in substantial compliance with Wisconsin statutes and administrative codes governing Residential Care Apartment Complexes (RCAC).
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 89, resulting in a Statement of Deficiency #64R312 and imposition of a forfeiture totaling $2,640.00. The operator was ordered to comply with requirements immediately and submit a Plan of Correction.
Complaint Details
The visit was complaint-related, conducted to verify compliance with applicable statutes and administrative codes. The Department issued a Statement of Deficiency and imposed forfeiture for violations found during the investigation.
Report Facts
Forfeiture amount: 2640 Reduced forfeiture amount: 1716 Forfeiture tag U189: 600 Forfeiture tag U267: 2040 Revisit inspection fee: 200 Compliance timeframe: 45 Plan of Correction submission timeframe: 10 Forfeiture payment timeframe: 10 Appeal request timeframe: 10 Revisit fee payment timeframe: 10
Employees Mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the notice letter
Mary Beth HoffmanAssisted Living Regional DirectorContact person for questions about the letter
Inspection Report Complaint Investigation Census: 86 Deficiencies: 4 Sep 25, 2025
Visit Reason
Surveyor completed a complaint investigation and a verification visit at Home Harbor following a complaint alleging medication issues and lack of nursing services.
Findings
Four total deficiencies were identified including failure to provide nursing services for medication administration and management, medication administration without proper delegation or supervision, missing and expired medications, and incomplete or late risk agreements for tenants. One complaint was substantiated.
Complaint Details
One complaint was substantiated regarding medication administration failures, missing medications, and lack of nursing oversight.
Deficiencies (4)
Description
Provider did not ensure nursing services were provided to all tenants for medication administration and medication management.
Medication administration and management were performed without supervision or delegation by a nurse or pharmacist from 05/24/2025 through the survey date.
Four tenants did not have signed, jointly negotiated risk agreements by the date of occupancy or with additional risks identified.
Tenant 2 did not receive all prescribed medications, missing a total of 68 doses over a 32-day period due to medication discontinuation errors and medication delivery issues.
Report Facts
Deficiencies identified: 4 Census: 86 Missed medication doses: 68 Revisit fee: 200
Employees Mentioned
NameTitleContext
CSM JCare Staff ManagerReported unawareness of responsibility for medication cart checks and described delegation status of medication passers.
DRC IDirector of Resident CareResponsible for clinical services and hiring nurses; reported management structure and delegation issues.
ED GExecutive DirectorReported staffing changes, agency nurse involvement, and medication cart checks.
RN MRegistered NurseNewly hired nurse working on medication handbook and delegation of medication passers.
LPN DLicensed Practical NurseFormer nurse who delegated medication passers; no longer employed since May 2025.
PHH SPresident of Home HarborExpressed confidence in new staff team to correct deficiencies.
Interim Executive Director KInterim Executive DirectorConfirmed delegation status and medication management issues.
POAHC OPower of Attorney for Health CareProvided medication list and discussed medication discontinuation issues for Tenant 2.
Inspection Report Complaint Investigation Deficiencies: 0 Apr 24, 2025
Visit Reason
Two complaint investigations were concluded for Home Harbor on April 24, 2025, to determine if the facility 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 (SOD #64R311) and imposed forfeitures totaling $440.00 for specific code violations.
Complaint Details
Two complaint investigations were conducted and concluded on April 24, 2025, for Home Harbor to assess compliance with applicable statutes and administrative codes.
Report Facts
Forfeiture amount: 440 Forfeiture amount: 200 Forfeiture amount: 240 Reduced forfeiture amount: 286 Days to comply: 45 Days to submit plan of correction: 10 Days to pay forfeiture: 10 Days to request appeal hearing: 10
Employees Mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the notice letter
Mary Beth HoffmanAssisted Living Regional DirectorContact person for questions about the letter
Inspection Report Complaint Investigation Census: 82 Deficiencies: 2 Apr 24, 2025
Visit Reason
The surveyor completed 2 complaint investigations at Home Harbor, resulting in identification of 2 deficiencies; one complaint was substantiated and one was unsubstantiated.
Findings
The provider failed to have a signed, jointly negotiated risk agreement for Tenant 1 by the date of occupancy, and Tenant 1 missed multiple doses of prescribed medications over a 3-day period due to medication management issues.
Complaint Details
Two complaints were investigated; one was substantiated and one was unsubstantiated.
Deficiencies (2)
Description
Provider did not ensure Tenant 1 had a signed, jointly negotiated risk agreement by the date of occupancy, resulting in missed medications.
Provider did not ensure Tenant 1 received all medications as prescribed, with missed doses of hydrocodone/acetaminophen, lorazepam, and morphine sulfate within a 3-day period.
Report Facts
Missed medication doses: 8 Census: 82
Employees Mentioned
NameTitleContext
Executive Director AExecutive DirectorInterviewed regarding risk agreements and medication management issues for Tenant 1.
Licensed Practical Nurse DLicensed Practical NurseInterviewed and reported on medication management and care issues for Tenant 1.
Inspection Report Complaint Investigation Census: 92 Deficiencies: 0 Sep 20, 2024
Visit Reason
The inspection visit was conducted to conclude two complaint investigations at Home Harbor.
Findings
No deficiencies were identified during the complaint investigations.
Complaint Details
Two complaint investigations were concluded with no deficiencies identified.
Inspection Report Follow-Up Census: 100 Deficiencies: 0 Sep 28, 2023
Visit Reason
Surveyor conducted a verification visit for previous Statements of Deficiencies dated 01/06/2023 and 03/01/2023, a standard survey, and two complaint investigations at Home Harbor.
Findings
No deficiencies were identified during the visit. Two complaints were found to be unsubstantiated. A $200 revisit fee is being assessed under statutory provisions.
Complaint Details
Two complaints were investigated and found to be unsubstantiated.
Report Facts
Revisit fee: 200
Inspection Report Complaint Investigation Census: 101 Capacity: 110 Deficiencies: 2 Mar 1, 2023
Visit Reason
The inspection was conducted following allegations of possible misappropriation of tenant property at the Residential Care Apartment Complex (RCAC). The Executive Director was made aware of the incident and the investigation was ongoing during the survey.
Findings
The facility failed to immediately investigate or protect tenants from possible misconduct after learning of alleged misappropriation. The Executive Director did not promptly contact law enforcement and delayed the internal investigation. A caregiver was suspended and later terminated based on the investigation. The facility also failed to report the allegation to the department as required.
Complaint Details
The complaint involved alleged misappropriation of Tenant 1's jewelry and money totaling over $5,000 and more than $60 respectively. Tenant 1 reported missing items while hospitalized. The Executive Director delayed contacting law enforcement and did not immediately start an internal investigation. A caregiver was suspended and terminated following the investigation. The facility did not submit a caregiver misconduct report to the Office of Caregiver Quality.
Deficiencies (2)
Description
Failure to investigate or take necessary steps to protect tenants from possible misconduct while the investigation was pending.
Failure to report allegations of misappropriation of tenant property by an employee to the department as required.
Report Facts
Licensed capacity: 110 Current census: 101 Jewelry value missing: 5000 Money missing: 60 Caregiver suspension date: Feb 17, 2023 Caregiver termination date: Feb 22, 2023
Employees Mentioned
NameTitleContext
ED AExecutive DirectorNamed in findings for failure to promptly investigate and report misappropriation allegations
CG BCaregiverSuspended and terminated following investigation of alleged misappropriation

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