Inspection Reports for LakeHouse Cedarburg
W56 N225 McKinley Blvd, Cedarburg, WI, 53012
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
25 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 25
Deficiencies: 0
Date: Jun 5, 2025
Visit Reason
A verification visit was conducted at LakeHouse Cedarburg to assess correction of previous deficiencies, with additional information gathered through 06/09/2025.
Findings
Previous deficiencies were corrected and no new deficiencies were identified during the survey.
Report Facts
Revisit fee: 200
Inspection Report
Enforcement
Deficiencies: 0
Date: May 21, 2025
Visit Reason
A Verification Visit was conducted on May 21, 2025, to determine if LakeHouse Cedarburg was in substantial compliance with Wisconsin Statutes and Administrative Code governing community-based residential facilities (CBRF). The visit was to investigate violations and enforce compliance.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83 at LakeHouse Cedarburg, resulting in a Statement of Deficiency (SOD) #XCCR12. The facility was placed on probationary license status with orders to comply, not admit new residents, and correct all violations. A total forfeiture of $1,550 was imposed for the violations.
Report Facts
Forfeiture amount: 1550
Reduced forfeiture amount: 1007.5
Forfeiture amount by tag: 900
Forfeiture amount by tag: 200
Forfeiture amount by tag: 450
Inspection fee: 200
Probationary license expiration date: 06/26/2025 (date by which compliance must be achieved)
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
Re-Inspection
Census: 25
Capacity: 65
Deficiencies: 4
Date: May 19, 2025
Visit Reason
The survey was conducted as a verification visit for previously cited Statement of Deficiencies (SOD) TXMN11 and XCCR11 to assess correction of repeat deficiencies and compliance with regulatory requirements.
Findings
Four repeat deficiencies were identified related to admission agreements, medication administration documentation, sprinkler system maintenance, and provision of adequate care within facility capacity. The provider was cited for not having admission agreements for 9 of 25 residents, failure to properly document medication administration, sprinkler system deficiencies per NFPA 25 standards, and inadequate staffing leading to delayed response times to resident calls.
Deficiencies (4)
Provider did not have an Admission Agreement for 9 of 25 residents providing information regarding services and accommodations including charges for services.
Person administering residents' medications or treatments did not initial the medication administration record (MAR) after administration.
Sprinkler system was not maintained in accordance with NFPA 25 requirements, including failed auxiliary drain, dry valve, control valves lacking proper identification, and failed fire department connection inspection.
Provider did not ensure adequate and appropriate care was provided within the capacity of the facility, evidenced by multiple residents experiencing long wait times for staff response to call pendants and staffing shortages.
Report Facts
Revisit fee: 200
Deficiencies cited: 4
Residents without admission agreement: 9
Facility licensed capacity: 65
Current census: 25
Medication administration exceptions: 12
Resident call wait times: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Executive Director | Interviewed regarding admission agreements, sprinkler system repairs, staff re-education on medication pass, and staffing concerns. |
| Caregiver E | Caregiver | Interviewed about medication administration practices and staffing shortages. |
| Team Lead F | Team Lead | Interviewed about medication pass timing and procedures. |
| RN G | Registered Nurse | Re-educated caregiver on medication pass and medication administration procedures. |
| Maintenance Director D | Maintenance Director | Responsible for scheduling sprinkler system repairs and was cooking lunch due to staffing shortages. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 21, 2025
Visit Reason
A Complaint Investigation was conducted on April 21, 2025, for LakeHouse Cedarburg to determine if the facility was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, concluding a Complaint Investigation to assess compliance with statutory and administrative requirements. The Department found violations substantiated, resulting in enforcement actions including a forfeiture.
Findings
The Department issued a Statement of Deficiency (SOD) #TXMN11 identifying violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A total forfeiture of $800 was imposed due to these violations, and the facility was placed on a probationary license requiring correction of all violations prior to license expiration on June 30, 2025.
Deficiencies (1)
Violations identified in Statement of Deficiency (SOD) #TXMN11 related to Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83
Report Facts
Forfeiture amount: 800
Reduced forfeiture amount: 520
Forfeiture payment timeframe: 10
Probationary license expiration date: Jun 30, 2025
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: 25
Capacity: 65
Deficiencies: 3
Date: Apr 16, 2025
Visit Reason
The survey was conducted as a complaint investigation triggered by allegations of inadequate care, including long wait times for assistance and medication administration issues at LakeHouse Cedarburg.
Complaint Details
One complaint was substantiated regarding long wait times for resident assistance and medication administration issues.
Findings
The investigation substantiated one complaint and identified three deficiencies related to medication administration documentation, medication storage security, and inadequate and inappropriate care evidenced by long wait times for resident assistance and incomplete shower documentation.
Deficiencies (3)
Failure to ensure medication administration records were initialed after administration, including medications and insulin left unattended in resident rooms.
Failure to ensure medications for all 25 residents were securely stored; medication carts were found unlocked with keys left in the lock.
Failure to provide adequate and appropriate care within the facility's capacity, including long wait times for resident call pendant responses and incomplete shower documentation.
Report Facts
Census: 25
Total Capacity: 65
Deficiencies identified: 3
Wait times over 20 minutes: 40
Wait times over 20 minutes: 40
Wait times over 20 minutes: 40
Wait times over 20 minutes: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Interviewed regarding medication administration, medication storage, and shower documentation; acknowledged deficiencies and plans to audit and improve compliance. |
| Caregiver C | Caregiver | Interviewed regarding medication administration practices and medication cart security; acknowledged leaving medications unattended and locking carts. |
| Caregiver D | Caregiver | Counseled on proper documentation of pain patch removal after admitting to marking exceptions without proper observation. |
| Caregiver F | Caregiver | Observed locking medication carts and removing keys after finding them unlocked. |
| Caregiver G | Caregiver | Found leaving medication cart unlocked with keys inside; keys taken away by RN B. |
| Executive Director A | Executive Director | Communicated with Surveyor and provided information from RN B. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 25, 2025
Visit Reason
A Standard Survey and Complaint Investigation were conducted to determine if Lakehouse Cedarburg 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. The Department found violations substantiated as detailed in SOD #XCCR11.
Findings
The Department issued a Statement of Deficiency (SOD #XCCR11) identifying violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A forfeiture of $600 was imposed for these violations, with a reduced payment option of $390 if not appealed.
Report Facts
Forfeiture amount: 600
Reduced forfeiture amount: 390
Forfeiture amount by tag: 400
Forfeiture amount by tag: 200
Probationary license expiration date: Jun 30, 2025
Inspection fee: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 65
Deficiencies: 9
Date: Feb 18, 2025
Visit Reason
Surveyor conducted one complaint investigation and standard survey at LakeHouse Cedarburg, gathering additional information through 02/25/2025.
Complaint Details
One complaint investigation was conducted and found unsubstantiated.
Findings
Nine deficiencies were identified including incomplete caregiver background checks, lack of employee orientation and training, missing admission agreements, unsafe and unclean living environment, incomplete fire drill documentation, malfunctioning smoke and heat detectors, sprinkler system deficiencies, and non-functioning emergency egress lighting.
Deficiencies (9)
Provider did not ensure 1 out of 2 employees had a complete caregiver background check done upon hire.
Provider did not ensure 1 of 2 employees obtained required orientation training before performing job duties.
Provider did not ensure 1 of 2 employees obtained all required training within 90 days after starting employment, including challenging behaviors and client group training.
Provider did not have admission agreements for 15 of 29 residents including information on services and charges.
Provider did not ensure a living environment that was safe, clean, comfortable, and homelike; multiple resident rooms and common areas were dirty or damaged, and there was a sewer smell.
Provider did not ensure quarterly fire drill reports documented total evacuation times or resident evacuation times for 2 of 2 quarters in 2024.
Provider did not ensure smoke and heat detectors were maintained in accordance with NFPA 72; fire alarm inspection showed failures in kitchen pull station, heat detector, and fire alarm panel batteries.
Provider did not ensure sprinkler system was maintained per NFPA 25; quarterly inspection showed failed dry valve and control valve with missing identification signs and other deficiencies.
Provider did not ensure all emergency egress lighting units were functioning with a stand-by power source; lighting near room 2 did not work and inspection reports showed multiple service needs without evidence of repair.
Report Facts
Deficiencies identified: 9
Residents present: 29
Licensed capacity: 65
Fire drills missing evacuation times: 2
Residents without admission agreements: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver B | Caregiver | Named in deficiency for incomplete caregiver background check. |
| Caregiver C | Caregiver | Named in deficiencies for lack of orientation and required training. |
| Executive Director A | Executive Director | Interviewed regarding multiple deficiencies and facility operations. |
| Maintenance Director D | Maintenance Director | Interviewed regarding environmental concerns, fire drills, and equipment maintenance. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 25, 2024
Visit Reason
A Complaint Investigation was conducted on November 25, 2024, to determine if Lakehouse Cedarburg was in substantial compliance with Wisconsin Statutes and Administrative Code requirements for community-based residential facilities.
Complaint Details
Complaint Investigation concluded on November 25, 2024, resulting in issuance of Statement of Deficiency #QK1Z11 for violations of applicable statutes and administrative codes.
Findings
The Department issued a Statement of Deficiency (SOD #QK1Z11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, establishing grounds for regulatory action and requiring the licensee to comply with all requirements within 45 days.
Report Facts
Days to achieve compliance: 45
Appeal filing deadline: 10
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: 27
Deficiencies: 1
Date: Nov 15, 2024
Visit Reason
Surveyor conducted two complaint investigations at LakeHouse Cedarburg due to concerns including Resident 1 being left unattended without oxygen and Resident 2's cognitive deficits and alcohol consumption history.
Complaint Details
Two complaints were substantiated. Resident 1 was left unattended without oxygen on the night of 09/06/2024 into 09/07/2024. Resident 2 had cognitive deficits and a history of alcohol consumption that was not documented in the ISP.
Findings
One deficiency was identified related to the provider's failure to review and revise individual service plans (ISP) annually or upon change of condition for two residents. Resident 1's ISP did not reflect oxygen use despite orders, and Resident 2's ISP did not document alcohol consumption or related interventions.
Deficiencies (1)
Provider did not review and revise the individual service plan annually or on change of condition for two residents, including failure to update Resident 1's oxygen needs and Resident 2's alcohol consumption history.
Report Facts
Census: 27
Deficiencies identified: 1
Complaints substantiated: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| A | Executive Director | Provided investigation and interviews related to Resident 1 and Resident 2's care and ISPs |
| B | Director of Health and Wellness | Interviewed regarding oxygen orders and ISP updates for Resident 1 |
| C | Caregiver | Completed ISPs for Resident 1 and Resident 2 |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 0
Date: Aug 12, 2024
Visit Reason
Surveyors conducted one complaint investigation at LakeHouse Cedarburg on 08/12/2024.
Complaint Details
Complaint investigation was unsubstantiated with no deficiencies identified.
Findings
The complaint was unsubstantiated and no deficiency was identified during the investigation.
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