Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
34 residents
Based on a August 2025 inspection.
Census over time
Inspection Report
Follow-Up
Census: 34
Deficiencies: 0
Date: Aug 27, 2025
Visit Reason
Surveyor conducted a verification visit at McFarland Villa Assisted Living to verify correction of a previous deficiency.
Findings
No violations of Chapter DHS 83 were issued during this survey. One deficiency from a previous statement of deficiency dated 04/30/2025 was substantially corrected.
Report Facts
Revisit fee: 200
Inspection Report
Routine
Census: 30
Deficiencies: 1
Date: Apr 30, 2025
Visit Reason
From 04/28/2025 through 04/30/2025, the Bureau of Assisted Living, Southern Regional Office, conducted a standard survey at McFarland Villa Assisted Living, a CBRF located in McFarland, WI.
Findings
The survey found one deficiency related to continuing education requirements. Two staff training records reviewed did not show at least 15 hours of continuing education per calendar year as required, including training in resident rights and medications.
Deficiencies (1)
The provider did not ensure resident care staff received at least 15 hours per calendar year of continuing education beginning with the first full calendar year of employment, including required topics such as standard precautions, client group related training, medications, resident rights, prevention and reporting of abuse, neglect and misappropriation, and fire safety and emergency procedures.
Report Facts
Census: 30
Continuing education hours: 6
Continuing education hours: 7
Continuing education hours: 12.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Coordinator A | Named in continuing education deficiency finding | |
| Caregiver B | Named in continuing education deficiency finding | |
| Operations Manager C | Operations Manager | Acknowledged deficiencies in staff continuing education documentation |
Notice
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
A standard survey was conducted on April 30, 2025, to determine if McFarland Villa Assisted Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency #XL1G11 and imposition of a forfeiture of $400.00. The licensee is ordered to comply with requirements within 45 days and may request an extension within 10 days.
Report Facts
Forfeiture amount: 400
Reduced forfeiture amount: 260
Compliance timeframe: 45
Appeal timeframe: 10
Payment timeframe: 10
Inspection fee: 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
Census: 32
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
Surveyor conducted a self-report review at McFarland Villa Assisted Living.
Findings
No deficiencies were identified during the survey.
Notice
Deficiencies: 0
Date: Feb 15, 2023
Visit Reason
A complaint investigation was conducted to determine if McFarland Villa Assisted Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
Complaint investigation concluded on 2023-02-15; violations found and Statement of Deficiency issued.
Findings
The Department issued a Statement of Deficiency for violations of Wisconsin Statutes and Administrative Code chapters related to the operation of the facility, requiring the licensee to comply with all requirements within 45 days.
Report Facts
Appeal filing timeframe: 10
Compliance timeframe: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Perron | Assisted Living Director | Signed the notice letter. |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Feb 14, 2023
Visit Reason
Surveyor conducted a complaint investigation for McFarland Villa Assisted Living regarding refunds returned within 30 days of discharge.
Complaint Details
The complaint was substantiated. On 02/10/2023, the Department received a complaint regarding refunds. Family Member B stated Resident 1 expired on 12/17/2022 and personal belongings were removed on 12/18/2022. The refund check was not received until 02/08/2023, after initially being told a refund would not be issued. Surveyor reviewed Resident 1's records and confirmed the refund was late.
Findings
One deficiency was identified related to the provider not returning a refund to a resident within 30 days after discharge as required by the admission agreement. The complaint was substantiated.
Deficiencies (1)
Refunds returned within 30 days of discharge not met; a refund for Resident 1 was not issued until 45 days after discharge.
Report Facts
Census: 33
Refund amount: 2292
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Executive Director | Discussed refund concerns and inconsistencies regarding refunds with surveyor |
Inspection Report
Routine
Deficiencies: 0
Date: Feb 1, 2023
Visit Reason
A standard survey and verification visit was conducted to determine if McFarland Villa Assisted Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #BQCW14) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A follow-up verification visit was conducted on the same date to determine if the violations were corrected, resulting in an imposed $200 inspection fee.
Report Facts
Inspection fee: 200
Appeal filing period: 10
Compliance correction period: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Perron | Assisted Living Director | Signed the notice and order letter |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Enforcement
Census: 32
Deficiencies: 3
Date: Feb 1, 2023
Visit Reason
The Bureau of Assisted Living, Southern Regional Office conducted an Enforcement Verification Visit and Standard Survey at McFarland Villa Assisted Living on 02/01/2023.
Findings
The survey identified 3 violations of Chapter DHS 83, including unclean toilet and bathing areas, failure to conduct quarterly fire evacuation drills with employees and residents, and failure to conduct semi-annual tornado, flooding, or other emergency evacuation drills. Two prior violations from 08/09/2022 were corrected. A $200 revisit fee is being assessed.
Deficiencies (3)
Toilet and bathing area not clean; sink faucets and countertops grossly covered in mineral deposits; toilet bowls stained; mal-odorous environment in resident restrooms.
Fire drills not conducted quarterly with both employees and residents; no nighttime simulated fire drill during 2022; fire drills not scheduled quarterly.
Other evacuation drills (tornado, flooding, or other emergency) not conducted at least semi-annually during 2022.
Report Facts
Violations issued: 3
Corrected violations: 2
Revisit fee: 200
Census: 32
Fire drills reviewed: 4
Severe weather/disaster drills performed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Clinical Marketing Lead I | Acknowledged concerns with cleanliness in resident toileting and bathing areas and discussed fire drill deficiencies. |
| Maintenance Director F | Maintenance Director | Acknowledged concerns with cleanliness and fire drill deficiencies; stated plans for quarterly fire drills and semi-annual severe weather drills. |
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