Inspection Reports for Mission Creek Senior Living
3217 Fiddlers Creek Dr, Waukesha, WI 53188, United States, WI, 53188
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
74% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
76 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 76
Deficiencies: 0
Date: Sep 8, 2025
Visit Reason
Surveyors conducted a standard licensing survey at Mission Creek, a CBRF in Waukesha, WI.
Findings
There were 0 deficiencies of Chapter DHS 83 identified during the survey.
Inspection Report
Follow-Up
Census: 74
Deficiencies: 0
Date: Oct 10, 2024
Visit Reason
The Bureau of Assisted Living, Southern Regional Office, conducted a verification visit for a Statement of Deficiency dated 05/03/2024 at Mission Creek, a community-based residential facility in Waukesha, WI.
Findings
As a result of the survey, no deficiencies were identified. A $200 revisit fee is being assessed under statutory provisions of Wis. Stat. Chapter 50.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 3, 2024
Visit Reason
The inspection was conducted as two complaint investigations and two verification visits to determine if Mission Creek was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, involving two complaint investigations and two verification visits. The report does not explicitly state substantiation status.
Findings
The Department issued a Statement of Deficiency #6GWJ12 for violations related to medication administration and documentation deficiencies. Enforcement actions including a forfeiture of $905 were imposed, and special orders were issued to ensure compliance with medication administration and notification requirements.
Deficiencies (1)
Medication administration and documentation deficiencies identified in Statement of Deficiency 6GWJ12
Report Facts
Forfeiture amount: 905
Reduced forfeiture amount: 588.25
Forfeiture component: 405
Forfeiture component: 500
Inspection fee: 200
Compliance timeframe: 45
Notification timeframe: 14
Extension request timeframe: 10
Revisit 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
Complaint Investigation
Census: 65
Deficiencies: 2
Date: May 3, 2024
Visit Reason
The Bureau of Assisted Living, Southern Regional Office, conducted 2 complaint investigations and 2 verification visits at Mission Creek, a community-based residential facility, following complaints related to medication administration and service plan updates.
Complaint Details
Two complaints were investigated and found to be unsubstantiated. The deficiencies identified were repeat deficiencies from prior Statements of Deficiency.
Findings
Two deficiencies were identified, both repeat deficiencies. One involved failure to ensure Resident 4 received prescribed insulin and medication as ordered, including documentation and administration errors. The other involved failure to update the individual service plan for Resident 5 when incontinence care needs increased, with concerns about pressure wounds and inadequate care.
Deficiencies (2)
Provider did not ensure Resident 4 received long-acting and rapid-acting insulin as prescribed, with blank entries in medication administration records and failure to administer Tresiba due to medication unavailability.
Provider did not ensure the individual service plan for Resident 5 was updated when incontinence care needs increased, resulting in inadequate repositioning and care, contributing to worsening pressure injuries.
Report Facts
Revisit fee: 200
Number of deficiencies identified: 2
Medication administrations missed: 5
Medication administrations missed: 5
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding medication administration and care concerns |
| Director of Wellness B | Director of Wellness | Interviewed regarding medication administration and care concerns |
| Pharmacy Technician G | Pharmacy Technician | Interviewed regarding medication refill and delivery issues |
| Medical Provider I | Medical Provider | Interviewed regarding concerns about Resident 5's care and pressure wounds |
| Caregiver J | Caregiver | Reported on Resident 5's condition and care needs |
| Caregiver K | Caregiver | Reported on Resident 5's care needs and staff practices |
| Manager L | Manager of Clinical Services | Interviewed regarding Resident 5's hospice care and incontinence concerns |
| Licensed Practical Nurse H | Licensed Practical Nurse | Interviewed regarding Resident 5's care plan updates |
| Nurse M | Nurse | Hospice nurse case manager who reported concerns about Resident 5's care |
| Resident Care Coordinator F | Resident Care Coordinator | Involved in care conferences and care plan discussions for Resident 5 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 9, 2024
Visit Reason
A complaint investigation was conducted on 02/09/2024 to determine if Mission Creek CBRF was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
Complaint investigation concluded on 02/09/2024 to assess compliance with statutory and administrative requirements for CBRF operation. Statement of Deficiency #6GWJ11 issued.
Findings
The Department issued a Statement of Deficiency (SOD #6GWJ11) identifying violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply immediately with requirements, develop corrective measures including fall prevention procedures, and provide training to staff. A forfeiture of $1,400 was imposed for the violations.
Deficiencies (1)
Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in Statement of Deficiency #6GWJ11
Report Facts
Forfeiture amount: 1400
Reduced forfeiture amount: 910
Forfeiture fee: 400
Forfeiture fee: 1000
Compliance timeframe: 45
Extension request timeframe: 10
Notice posting duration: 90
Appeal request timeframe: 10
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
Complaint Investigation
Census: 72
Deficiencies: 2
Date: Feb 8, 2024
Visit Reason
On 02/08/2024, the Bureau of Assisted Living, Southern Regional Office, conducted a complaint investigation at Mission Creek, a community-based residential facility in Waukesha, WI, due to allegations related to injury prevention measures and individual service plan implementation.
Complaint Details
The complaint was substantiated. The investigation focused on allegations of injury prevention measures not being used for residents who experienced falls out of bed.
Findings
Two repeat deficiencies were identified related to failure to implement and follow individual service plans for residents, specifically regarding fall prevention measures such as the use of fall mats. The complaint was substantiated with evidence including interviews, record reviews, and video screenshots showing inconsistent use of fall mats and incomplete updates to individual service plans for residents who experienced falls.
Deficiencies (2)
Failure to implement and follow Resident 1's individual service plan, specifically the use of a fall mat which was not used on three occasions in January 2023.
Failure to update individual service plans annually or when there are changes for three residents, including documented falls and interventions not reflected in the plans.
Report Facts
Deficiencies identified: 2
Resident falls: 3
Resident falls: 7
Resident falls: 8
Census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Executive Director | Interviewed regarding fall prevention and individual service plan implementation |
| Director of Wellness B | Director of Wellness | Interviewed regarding fall prevention and individual service plan implementation |
| Caregiver D | Interviewed about fall mat usage and resident care | |
| Nurse Case Manager C | Nurse Case Manager | Interviewed about hospice care and fall mat usage for Resident 1 |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Date: Dec 20, 2023
Visit Reason
The Bureau of Assisted Living, Southern Regional Office, conducted a complaint investigation at Mission Creek, a community-based residential facility located in Waukesha, WI.
Complaint Details
The complaint was unsubstantiated.
Findings
As a result of the survey, no deficiencies were identified. The complaint was unsubstantiated.
Report Facts
Census: 70
Deficiencies identified: 0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 19, 2023
Visit Reason
A verification visit and two complaint investigations were conducted to determine if Mission Creek was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, involving two complaint investigations concluded on 10/19/2023. Substantiation status is not explicitly stated.
Findings
The Department issued Statement of Deficiency (SOD) #45ON16 for violations related to medication administration and documentation deficiencies, resulting in a Notice of Violation and an imposed forfeiture.
Deficiencies (1)
Medication administration and documentation deficiencies identified in Statement of Deficiency 45ON16
Report Facts
Forfeiture amount: 1920
Reduced forfeiture amount: 1248
Inspection fee: 200
Revisit fee: 200
Compliance timeframe: 45
Notification timeframe: 14
Extension request timeframe: 10
Payment timeframe: 10
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
Complaint Investigation
Census: 73
Deficiencies: 2
Date: Oct 19, 2023
Visit Reason
On 10/19/2023, the Bureau of Assisted Living, Southern Regional Office, conducted a verification visit and two complaint investigations at Mission Creek, a community-based residential facility located in Waukesha, WI.
Complaint Details
One complaint was substantiated. One complaint was unsubstantiated.
Findings
Two deficiencies were identified, both repeat deficiencies related to medication administration. One complaint was substantiated and one was unsubstantiated. The provider did not ensure that residents received all prescribed medications at the intervals prescribed by a practitioner, and documentation of medication administration was incomplete for some residents.
Deficiencies (2)
Provider did not ensure 2 of 4 residents reviewed received all prescribed medications at the intervals prescribed by a practitioner; Residents 53 and 40 did not receive their insulin prior to meals as ordered.
Provider did not ensure the medication administration of 1 of 3 residents reviewed was accurately documented; Resident 53's Novolog 100 unit/ml sliding scale administration was not documented.
Report Facts
Revisit fee: 200
Census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manager DD | Manager | Observed administering medications and confirmed medication administration times; admitted to late medication administration. |
| Director FF | MC Director | Interviewed regarding mealtimes and documentation concerns; acknowledged concerns and stated plans to provide education and change electronic charting. |
| Executive Director J | Executive Director | Acknowledged concern about insulin administration timing and documentation; stated education would be provided to caregivers. |
| RN GG | RN | Confirmed insulin was to be administered prior to meals and acknowledged concerns about occurrences of late administration. |
| Manager EE | Manager | Participated in review of concerns regarding insulin administration timing. |
Inspection Report
Enforcement
Deficiencies: 6
Date: Apr 27, 2023
Visit Reason
A standard survey and verification visit was conducted on April 27, 2023, to determine if Mission Creek was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities (CBRF). This visit resulted in a Statement of Deficiency and enforcement actions.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83 at Mission Creek, leading to a Notice of Violation and an imposed forfeiture totaling $4,900. The licensee was ordered to comply with all requirements immediately and maintain substantial compliance within 45 days.
Deficiencies (6)
Violation of DHS 83.32(3)(h)
Violation of DHS 83.35(3)(d)
Violation of DHS 83.37(1)(j)
Violation of DHS 83.38(1)(g)
Violation of DHS 83.44(2)(a)
Violation of DHS 83.45(3)
Report Facts
Forfeiture amount: 4900
Reduced forfeiture amount: 3185
Revisit 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
Routine
Census: 59
Capacity: 97
Deficiencies: 9
Date: Apr 25, 2023
Visit Reason
Surveyors conducted a verification visit and standard survey at Mission Creek to assess compliance with regulatory requirements and investigate grievances and medication administration.
Findings
Nine deficiencies were identified including medication administration errors, failure to update individual service plans after falls, lack of grievance resolution, failure to conduct resident satisfaction surveys, improper narcotic record keeping, inadequate health monitoring, unclean kitchen equipment, unclean resident rooms with odors, and unsecured toxic substances storage.
Deficiencies (9)
Residents did not receive all prescribed medications in the dosage and at intervals prescribed by a practitioner, including missed doses due to unavailable medication and medications found on floors.
Provider did not provide a written summary of grievances, findings, conclusions, or actions taken to residents or their representatives, and failed to maintain investigation records.
Individual service plans were not updated after multiple falls or to address continuous oxygen use and reminders.
Provider did not give residents or their legal representatives the opportunity to complete satisfaction evaluations annually.
Provider failed to maintain accurate proof-of-use records for schedule II drugs, including narcotic counts and daily audits.
Provider failed to document communication with physicians and health care providers and did not monitor weights and blood pressure as ordered for several residents.
Kitchen equipment and utensils were not maintained in a clean manner, including soiled scoops, ovens, and floors.
Resident rooms were not kept clean and free from odors, with urine odors, food debris, stains, and ants observed in multiple rooms.
Cleaning compounds, polishes, insecticides, and toxic substances were not stored in a secure area, with the riser room left unsecured containing multiple toxic substances.
Report Facts
Deficiencies identified: 9
Revisit fee: 200
Residents receiving schedule II narcotics: 22
Licensed capacity: 97
Current census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director J | Executive Director | Acknowledged medication administration issues, lack of grievance resolution, and narcotic count discrepancies. |
| Regional Nurse GG | Regional Nurse | Acknowledged medication administration issues, narcotic count discrepancies, and failure to monitor weights and blood pressure. |
| Housekeeper JJ | Housekeeper | Reported finding pills on floors and notifying management. |
| Caregiver II | Caregiver | Interviewed regarding medication availability and resident care concerns. |
| Lead Caregiver LL | Lead Caregiver | Observed administering medications late and documented narcotic counts. |
| Dining Director NN | Dining Director | Interviewed about kitchen cleanliness and condition of ovens. |
| Hospice Nurse KK | Hospice Nurse | Interviewed regarding resident falls and medication administration. |
| Caregiver MM | Caregiver | Observed passing medications and unable to complete narcotic counts due to staffing. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Feb 7, 2023
Visit Reason
Surveyor conducted a complaint investigation at Mission Creek based on a complaint received.
Complaint Details
The complaint was not substantiated.
Findings
The complaint was investigated and found to be not substantiated.
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