Inspection Reports for
Layton Terrace Senior Living
9200 W Layton Ave, Greenfield, WI 53228, United States, WI, 53228
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 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
16
12
8
4
0
Occupancy
Latest occupancy rate
84% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 14, 2025
Visit Reason
A verification visit and five complaint investigations were conducted to determine if Layton Terrace was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit included five complaint investigations concluded on October 14, 2025, to assess compliance with medication administration and documentation requirements.
Findings
The Department issued a Statement of Deficiency (SOD #JJ9F14) for violations related to medication administration and documentation. A total forfeiture of $1,000 was imposed for these violations, with specific orders to comply with medication administration requirements and corrective actions.
Deficiencies (2)
Tag N415, DHS Code 83.37(2)(d): The facility violated medication administration requirements, failing to ensure residents received prescribed medications as ordered.
Tag N432, DHS Code 83.83(1)(h): The facility failed to maintain proper medication documentation and management.
Report Facts
Forfeiture amount: 1000
Reduced forfeiture amount: 650
Inspection fee: 200
Compliance timeframe: 45
Notification timeframe: 7
Appeal timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter. |
| Kenneth Brotheridge | Assisted Living Director, Bureau of Assisted Living, Division of Quality Assurance | Signed the Notice and Order letter. |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 6
Date: Oct 14, 2025
Visit Reason
Surveyors completed a verification visit and 5 complaint investigations at Layton Terrace following complaints about inadequate resident care and medication administration.
Complaint Details
Two of five complaints were substantiated related to failure to provide services as specified in care plans and inaccurate medication administration.
Findings
Six deficiencies were identified including failure to develop and implement comprehensive individualized service plans, inaccurate medication administration documentation, failure to provide personal care as specified, and failure to maintain rooms free from odors. Two of five complaints were substantiated.
Deficiencies (6)
83.35(3)(a) Comprehensive Individualized Service Plan. The provider did not ensure Resident 17 had a comprehensive individualized service plan that identified needs, approaches, measurable goals, and care delivery methods including refusal of showers.
83.35(3)(c) Implement, follow the individual service plan. Residents 17 and 18 did not receive care as specified; Resident 17's laundry was not done regularly and Resident 18 was served food containing allergens.
83.37(2)(d) Documentation of medication administration. Medication administration records for Residents 17 and 13 were inaccurate with multiple missed doses and undocumented administrations.
83.38(1)(a) Personal care. Residents 17 and 18 did not receive personal care as directed in their service plans, including assistance with laundry and avoidance of allergens.
83.38(1)(h) Medication administration. Residents 17 and 13 did not receive appropriate medication administration; Resident 17 missed 3 doses and Resident 13 missed 15 doses over a 25-day period.
83.44(2)(a) Rooms clean and free from odors. There was a strong urine odor emanating from Resident 16's room and throughout the memory care unit, with soiled furniture and inadequate cleaning frequency.
Report Facts
Deficiencies identified: 6
Complaints investigated: 5
Complaints substantiated: 2
Revisit fee: 200
Resident census: 67
Missed medication doses for Resident 17: 3
Missed medication doses for Resident 13: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Person AA | Family member of Resident 17 interviewed regarding care and medication concerns. | |
| Executive Director BB | Executive Director | Interviewed regarding care tracking, medication administration, and odor complaints. |
| Health Services Director EE | Health Services Director | Interviewed regarding medication administration and care refusals. |
| Resident Care Coordinator FF | Resident Care Coordinator | Interviewed regarding Resident 17's hearing aids and care. |
| Medication Passer CC | Medication Passer | Interviewed regarding care sheet documentation and care completion. |
| Caregiver DD | Caregiver | Interviewed regarding care sheet documentation and care completion. |
| Community Director W | Community Director | Interviewed regarding odor issues in Resident 16's room and memory care unit. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 12, 2025
Visit Reason
A verification visit and complaint investigation was conducted on May 12, 2025, at Layton Terrace 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 and included a verification visit to determine compliance with applicable statutes and administrative codes. The Department issued a Statement of Deficiency and imposed enforcement actions.
Findings
The Department issued a Statement of Deficiency (SOD #JJ9F13) citing violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements, update residents' Individual Service Plans, and was assessed a total forfeiture of $1,500 for the violations.
Deficiencies (1)
Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #JJ9F13
Report Facts
Forfeiture amount: 1500
Reduced forfeiture amount: 975
Forfeiture tag N158: 500
Forfeiture tag N448: 1000
Inspection fee: 200
Compliance timeframe: 45
Extension request timeframe: 10
Revisit fee: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter |
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 4
Date: Apr 30, 2025
Visit Reason
The inspection was conducted as a verification visit and complaint investigation triggered by a complaint alleging misappropriation of property and dietary concerns at Layton Terrace.
Complaint Details
The complaint was received on 2025-02-25 alleging misappropriation of property and dietary needs not being addressed. The complaint was substantiated with four deficiencies identified.
Findings
The complaint was substantiated with four total deficiencies identified, including failure to conduct a thorough investigation of alleged misappropriation of resident property, inaccurate medication administration documentation, failure to provide medication administration appropriate to residents' needs, and failure to provide palatable food meeting dietary guidelines and special dietary needs of residents.
Deficiencies (4)
Failure to conduct and document a thorough investigation of an allegation of misappropriation of Resident 5's property, including failure to submit a required self-report and follow-up with police.
Failure to accurately document medication administration for Resident 5 on 16 occasions.
Failure to provide medication administration appropriate to the needs of Residents 6 and 7, including missed medications due to unavailability and unauthorized discontinuation.
Failure to provide palatable food meeting recommended dietary allowances and special dietary needs, including lack of diabetic-friendly options and failure to provide therapeutic diets as ordered for Residents 9, 12, and 13.
Report Facts
Deficiencies identified: 4
Residents present: 59
Medication documentation errors: 16
Diabetic residents: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director C | Executive Director | Responsible for conducting investigations and submitting self-reports; failed to submit self-report and conduct thorough investigation of misappropriation allegation |
| Director of Nursing U | Director of Nursing | Interviewed regarding medication administration errors and special diet accommodations |
| Care Coordinator V | Resident Care Coordinator | Responsible for medication cart and administration records; involved in meal planning for Resident 9 but not authorized to discontinue medications |
| Med Passer Z | Medication Passer | Failed to document medication administration for Resident 5 on two occasions |
| Community Director W | Community Director | Accompanied surveyor during lunch observation and interviewed about meal options |
| Chef Y | Chef | Responsible for kitchen operations and accommodating special diets; reported difficulty maintaining sugar-free items |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 1, 2024
Visit Reason
The inspection was conducted as a standard survey, verification visit, and three complaint investigations to determine if Layton Terrace was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit included three complaint investigations; however, substantiation status is not explicitly stated in the document.
Findings
The Department issued a Statement of Deficiency (SOD #JJ9F12) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a $200 forfeiture and an order to comply with requirements to protect resident health, safety, and welfare.
Deficiencies (1)
Violation of Wis. Admin. Code 83.37(2)(d) as identified in SOD #JJ9F12
Report Facts
Forfeiture amount: 200
Reduced forfeiture amount: 130
Revisit inspection fee: 200
Compliance timeframe: 45
Appeal timeframe: 10
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter |
| Kenneth Brotheridge | Assisted Living Director | Signed the notice and order letter |
Inspection Report
Routine
Census: 61
Deficiencies: 4
Date: Nov 1, 2024
Visit Reason
The surveyor conducted a standard survey, verification visit, and three complaint investigations at Layton Terrace on 11/01/2024.
Complaint Details
Three complaints were investigated and found to be unsubstantiated.
Findings
Four deficiencies were identified, including one repeat violation. Three complaints were unsubstantiated. Deficiencies involved failure to report serious injury incidents timely, lack of resident/legal representative involvement in service plan development, inaccurate medication administration documentation, and failure to ensure medication administration for a resident.
Deficiencies (4)
Failure to submit a written report to the department within 3 working days after an incident resulting in emergency room treatment and hospitalization for a resident.
Failure to ensure the resident and/or legal representative were involved in developing and signing the individual service plan for 2 of 3 residents reviewed.
Failure to accurately maintain medication administration records for 1 resident, including missing staff initials and unavailable medications.
Failure to ensure medication administration was provided to 1 resident as prescribed from 09/01/2024 to 09/30/2024.
Report Facts
Deficiencies identified: 4
Repeat deficiencies: 1
Revisit fee: 200
Census: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| G | Senior Executive Director (SED) | Interviewed regarding incident reporting and service plan development. |
| H | Director of Nursing (DON) | Interviewed regarding incident reporting and service plan development. |
| D | Nurse (DON) | Provided self-report for incident and confirmed document provision. |
| Q | Regional Director of Nursing (RDON) | Interviewed regarding medication administration and MAR review. |
| R | Regional Director of Operations (RDOO) | Reviewed documentation with surveyor. |
| E | Caregiver | Interviewed regarding medication availability and resident refusals. |
| I | Caregiver | Interviewed regarding medication availability and resident refusals. |
| P | Facility Nurse (DON) | Signed ISP for Resident 3. |
| K | Director of Nursing (DON) | Believed to have reviewed initial evaluation with resident's power of attorney. |
| C | Executive Director | Confirmed provision of resident files and involved in ISP discussions. |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 2
Date: Jun 26, 2024
Visit Reason
The surveyor completed a complaint investigation at Layton Terrace following a complaint received on 04/18/2024 regarding a resident not receiving her/his medications.
Complaint Details
The complaint was substantiated. It involved Resident 1 not receiving medications as prescribed and inadequate health monitoring, including missing documentation of vital signs and weights, and failure to notify physicians of critical health indicators.
Findings
Two deficiencies were identified: inaccurate documentation of medication administration for one resident, and failure to monitor health and make arrangements for physical health services, including daily weight and oxygen saturation monitoring as ordered. One complaint was substantiated.
Deficiencies (2)
The provider did not ensure each resident's medication administration record (MAR) was accurately maintained for Resident 1, with multiple dates missing staff initials indicating medication administration.
The provider did not monitor the health and make arrangements for physical health services for Resident 1, including failure to monitor weight and oxygen saturation as ordered on a daily basis.
Report Facts
Census: 65
Deficiencies identified: 2
Dates missing medication administration initials: 40
Days vitals refused: 11
Weight discrepancy: 60
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 26, 2024
Visit Reason
A complaint investigation was conducted on June 26, 2024, to determine if Layton Terrace was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The investigation was complaint-driven and concluded that the facility was not in substantial compliance, leading to issuance of a Statement of Deficiency and enforcement actions.
Findings
The Department issued a Statement of Deficiency (SOD #JJ9F11) for violations related to health monitoring and other regulatory requirements, resulting in an order to comply and imposed forfeiture.
Deficiencies (2)
Health monitoring deficiency under Wis. Admin. Code § DHS 83.38(1)(g)
Violation of Wis. Admin. Code § 83.37(2)(d)
Report Facts
Forfeiture amount: 870
Reduced forfeiture amount: 565.5
Forfeiture for violation N415 83.37(2)(d): 150
Forfeiture for violation N431 83.38(1)(g): 720
Compliance timeframe: 45
Extension request timeframe: 10
Forfeiture payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter |
| Kenneth Brotheridge | Assisted Living Director | Signed the notice and order letter |
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
Surveyor conducted a complaint investigation at Layton Terrace on 10/25/2023.
Complaint Details
One complaint was investigated and found to be unsubstantiated.
Findings
No deficiencies were identified during the complaint investigation. The complaint was unsubstantiated.
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Date: Jun 14, 2023
Visit Reason
Surveyor completed 2 complaint investigations at Layton Terrace on 06/14/2023.
Complaint Details
Two complaints were investigated and found to be unsubstantiated.
Findings
No deficiencies were identified as a result of the complaint investigations. Two complaints were unsubstantiated.
Report Facts
Complaints investigated: 2
Census: 64
Inspection Report
Re-Inspection
Census: 58
Deficiencies: 0
Date: Mar 21, 2023
Visit Reason
Surveyor completed a verification visit at Layton Terrace to verify correction of previous deficiencies.
Findings
No deficiencies were identified during the verification visit.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 20, 2023
Visit Reason
A standard survey, two complaint investigations, and a self-report review were conducted to determine if Layton Terrace was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit included two complaint investigations and a self-report review, but the substantiation status is not explicitly stated.
Findings
The Department issued a Statement of Deficiency (SOD #7IEO11) for violations of state statutes and administrative codes. A forfeiture of $150.00 was imposed for violations described in the SOD. The licensee was placed on probationary license status and ordered to correct all violations to achieve substantial compliance.
Report Facts
Forfeiture amount: 150
Reduced forfeiture amount: 112.5
Forfeiture payment timeframe: 10
Compliance timeframe: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter |
| Dan Perron | Assisted Living Director | Signed the notice and order letter |
Inspection Report
Routine
Census: 64
Capacity: 80
Deficiencies: 5
Date: Jan 20, 2023
Visit Reason
On 01/20/2023, a standard survey, two complaint investigations, and a self-report review were completed at Layton Terrace.
Complaint Details
Two complaint investigations were conducted; one complaint was substantiated regarding food safety and medication administration, and one complaint was unsubstantiated.
Findings
Five deficiencies were identified including failure to document employee communicable disease screening, incomplete employee training and orientation documentation, medication administration error, and failure to maintain safe food temperatures during service.
Deficiencies (5)
Provider did not ensure documentation was obtained indicating employees were screened for clinically apparent communicable disease.
Provider did not ensure required employee training was documented for employees employed over 90 days.
Provider did not ensure required orientation training was documented for employees.
Provider did not ensure all medications were administered at the prescribed dose; Resident 1 received 14 units of Novolog instead of 15 units.
Provider did not ensure all food was held at safe temperatures prior to serving; food temperatures were not taken or recorded, and hot food was served below 140°F.
Report Facts
Deficiencies identified: 5
Residents present: 64
Total licensed capacity: 80
Medication dosage error: 1
Food temperature measured: 120.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver D | Caregiver | Named in communicable disease screening deficiency and medication administration error. |
| Caregiver E | Caregiver | Named in communicable disease screening deficiency and food service temperature observation. |
| Caregiver F | Caregiver | Named in communicable disease screening and training documentation deficiencies. |
| Executive Director A | Executive Director | Interviewed regarding communicable disease screening, training, orientation, medication error, and food temperature procedures. |
| Health Services Director B | Health Services Director | Interviewed regarding communicable disease screening and medication pass observation. |
| Registered Nurse C | Registered Nurse | Interviewed regarding medication error and food temperature monitoring. |
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