Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
62 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Date: Oct 28, 2025
Visit Reason
Surveyors conducted a complaint investigation at Monroe Manor to investigate a complaint received.
Complaint Details
The complaint was unsubstantiated.
Findings
The complaint was unsubstantiated and no new violations were identified during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 7, 2025
Visit Reason
A complaint investigation and verification visit was conducted on October 7, 2025, to determine if Monroe Manor was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, conducted to verify compliance with applicable statutes and administrative codes. The Department issued a Statement of Deficiency #77PW12 and imposed enforcement actions including forfeiture and orders to comply.
Findings
The Department issued a Statement of Deficiency (SOD #77PW12) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply immediately and corrective actions including staff training were mandated. A total forfeiture of $1010 was imposed for specific violations, with a reduced payment option available. Additionally, a $200 inspection fee was assessed for a revisit to verify correction of prior deficiencies.
Report Facts
Forfeiture amount: 1010
Reduced forfeiture amount: 656.5
Forfeiture amount: 210
Forfeiture amount: 600
Forfeiture amount: 200
Inspection fee: 200
Compliance timeframe: 45
Appeal timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 82
Deficiencies: 3
Date: Sep 30, 2025
Visit Reason
Surveyors conducted a verification visit and complaint investigation triggered by complaints about resident care at Monroe Manor.
Complaint Details
Four of six complaints were unsubstantiated; two of six complaints were substantiated. The investigation included review of medication administration, individual service plan adherence, and exit obstruction.
Findings
Two of six complaints were substantiated, resulting in three identified violations, including medication administration errors, failure to follow individual service plans, and obstructed emergency exits. Repeat violations were noted for medication administration and exit obstruction.
Deficiencies (3)
Provider did not ensure prescribed medications were administered in the dosage and at intervals prescribed by a practitioner; Resident 2 did not receive Morphine as prescribed.
Provider did not follow the individual service plan as written; bowel movements, safety checks, and toileting were not done for Resident 1.
Provider did not ensure all exits were unobstructed; exit stairwell on the southwest hall of the main floor was blocked by 2 wheelchairs and a walker.
Report Facts
Revisit fee: 200
Census: 64
Total licensed capacity: 82
Medication doses missed: 7
Incidents of toileting not signed off: 61
Incidents of bowel movement not signed off: 26
Incidents of safety checks not signed off: 100
Incidents of independent bowel movements recorded: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding resident care concerns and exit obstruction findings. |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding medication administration issues, order entry delays, and bowel movement tracking. |
| Registered Nurse F | Registered Nurse | Former employee implicated in medication order follow-through concerns. |
| Managed Care Nurse C | Managed Care Nurse | Interviewed about Resident 1's care concerns and follow-up visits. |
| Managed Care Case Manager D | Managed Care Case Manager | Involved in increased visits to ensure care plan adherence. |
| POA E | Power of Attorney | Expressed concerns about care and follow-up communication. |
Notice
Deficiencies: 0
Date: Jul 15, 2025
Visit Reason
A standard survey, complaint, and self-report investigation were conducted to determine if Monroe Manor 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 (SOD #77PW11) and imposition of a $200 forfeiture.
Report Facts
Forfeiture amount: 200
Reduced forfeiture amount: 130
Forfeiture payment timeframe: 10
Compliance timeframe: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William R. Gardner | 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: 65
Capacity: 82
Deficiencies: 3
Date: Jul 14, 2025
Visit Reason
Surveyors conducted a standard survey, complaint investigation, and self-report investigation at Monroe Manor. Three complaints were investigated and found unsubstantiated.
Complaint Details
Three of 3 complaints were unsubstantiated.
Findings
Three new violations were identified, including a repeat deficiency. Deficiencies included failure to ensure all staff were screened for communicable diseases including tuberculosis upon hire, failure to conduct an annual onsite medication administration and storage review, and failure to maintain exit passageways and stairways unobstructed.
Deficiencies (3)
Provider did not ensure 3 of 4 staff sampled were screened for communicable disease, including tuberculosis, upon hire.
Provider did not ensure a physician, pharmacist, or registered nurse conducted an annual onsite review of medication administration and storage systems.
Exit stairwell on the southwest hall was blocked by a Velcro netting barrier and artificial tree, obstructing an emergency exit.
Report Facts
Number of complaints investigated: 3
Staff files reviewed: 4
Staff not screened for communicable disease: 3
Licensed capacity: 82
Current census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator D | Administrator | Interviewed regarding communicable disease screening, medication review, and exit obstruction. |
| Finance Director E | Finance Director | Mentioned as knowing communicable disease screens and TB tests were completed but unable to find documentation. |
| Human Resources Director F | Human Resources Director | Responsible for communicable disease screening but was terminated prior to inspection. |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
The surveyor completed a verification visit and three complaint investigations at Monroe Manor. The complaints were investigated and found to be unsubstantiated.
Complaint Details
Three complaints were investigated and found to be unsubstantiated.
Findings
No deficiencies were identified during the visit. A $200 revisit fee is being assessed under statutory provisions.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 15, 2024
Visit Reason
A verification visit, self-report, and complaint investigation was conducted to determine if Monroe Manor 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 and self-report. The Department issued a Statement of Deficiency (SOD #8ONJ13) based on violations found during the investigation.
Findings
The Department issued a Statement of Deficiency (SOD #8ONJ13) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements, develop and implement corrective measures including behavior management procedures, and provide staff training. A forfeiture of $500 was imposed with a reduced payment option of $325.
Report Facts
Forfeiture amount: 500
Reduced forfeiture amount: 325
Revisit inspection fee: 200
Compliance timeframe: 45
Payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William R. Gardner | 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: 58
Capacity: 82
Deficiencies: 1
Date: Oct 9, 2024
Visit Reason
Surveyors conducted a verification visit, investigated a complaint and a self-report at Monroe Manor. The complaint alleged that a resident was not receiving adequate care.
Complaint Details
The complaint was substantiated. Resident 1 had a rash and was not receiving adequate bathing care, receiving only 5 showers from April to October 2024 despite care plan specifying twice weekly showers. Staff documented multiple refusals and limited attempts to encourage showering. The provider had not implemented sufficient interventions beyond reapproaching and consulting the resident's POA and managed care organization.
Findings
The complaint was substantiated with one new deficiency identified. The provider did not ensure services were provided to manage residents' behaviors that may be harmful to themselves or others, specifically failing to provide adequate bathing care to Resident 1 who was showered approximately 5 times in 7 months despite care plan requirements.
Deficiencies (1)
Provider did not provide services to manage residents' behaviors that may be harmful to themselves or others, evidenced by failure to ensure Resident 1 received regular bathing care.
Report Facts
Revisit fee: 200
Census: 58
Total licensed capacity: 82
Showers received: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding Resident 1's showering care and interventions |
| Nurse Manager B | Nurse Manager | Interviewed about resident skin checks and shower care interventions |
| Registered Nurse C | Registered Nurse | Interviewed about Resident 1's rash and bathing care |
| Human Resource Director D | Human Resource Director | Interviewed regarding Resident 1's care |
| Caregiver E | Caregiver | Interviewed about Resident 1's rash and shower refusals |
| Power of Attorney F | Power of Attorney | Resident 1's POA involved in care discussions |
| Case Manager G | Case Manager | Interviewed about Resident 1's rash and care |
| Registered Nurse H | Registered Nurse | Interviewed about Resident 1's bathing care and staff reminders |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 13, 2024
Visit Reason
A complaint investigation and verification visit was conducted to determine if Monroe Manor was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was a complaint investigation and verification visit to determine compliance with applicable statutes and codes. The Department issued a Statement of Deficiency and imposed enforcement actions including forfeiture.
Findings
The Department issued a Statement of Deficiency (SOD #8ONJ12) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply immediately with all laws governing the facility and to develop corrective measures addressing caregiver misconduct and other deficiencies. A total forfeiture of $2200 was imposed for the violations.
Deficiencies (1)
Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as detailed in Statement of Deficiency #8ONJ12
Report Facts
Forfeiture amount: 2200
Reduced forfeiture amount: 1430
Forfeiture amounts by tag: 500
Forfeiture amounts by tag: 900
Forfeiture amounts by tag: 300
Forfeiture amounts by tag: 200
Forfeiture amounts by tag: 300
Inspection fee: 200
Compliance timeframe: 45
Investigation report submission timeframe: 14
Notification timeframe: 7
Extension request timeframe: 10
Forfeiture payment timeframe: 10
Revisit fee payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William R. Gardner | 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: 61
Capacity: 82
Deficiencies: 6
Date: Mar 6, 2024
Visit Reason
The survey was conducted as a complaint and verification visit triggered by allegations of missing money and caregiver misconduct at Monroe Manor.
Complaint Details
The complaint was substantiated. It involved allegations of missing money from residents and failure to properly investigate and notify legal representatives.
Findings
Six deficiencies were identified, including failure to investigate and document allegations of misappropriation of property, failure to notify legal representatives within 72 hours of allegations, failure to comply with Department orders regarding caregiver misconduct, failure to conduct caregiver background checks, failure to maintain current employee records, and failure to conduct required emergency evacuation drills.
Deficiencies (6)
Failure to investigate and document allegations of missing money for Residents 6, 10, and 11.
Failure to notify residents' legal representatives within 72 hours of allegations of misappropriation of property.
Failure to comply with Department orders regarding caregiver misconduct, including lack of in-service training and unclear reporting responsibilities.
Failure to conduct and document a caregiver background check for Administrator M.
Failure to maintain a current employee record for Administrator M.
Failure to conduct tornado, flooding, or other emergency or disaster evacuation drills at least semi-annually; only one severe weather drill was conducted in 2023.
Report Facts
Revisit fee: 200
Number of deficiencies identified: 6
Number of repeat deficiencies: 3
Census: 61
Total capacity: 82
Missing money amounts: 20
Missing money amounts: 70
Severe weather drills conducted: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator M | Administrator | Named as current administrator but lacked a current caregiver background check and employee record |
| General Manager A | General Manager | Named as acting administrator and involved in investigation and reporting of missing money allegations |
| Human Resources Manager C | Human Resources Manager | Responsible for caregiver investigations and employee records; involved in investigation of missing money allegations |
| Office Manager D | Office Manager | Interviewed regarding missing money allegations and reporting procedures |
| Certified Medical Assistant N | Certified Medical Assistant | Reported missing money allegations to management and legal representatives |
| Nurse Manager B | Nurse Manager | Interviewed regarding reporting procedures for missing money allegations |
| Registered Nurse O | Registered Nurse | Interviewed regarding reporting procedures for missing money allegations |
| Maintenance Director H | Maintenance Director | Responsible for conducting emergency drills |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 31, 2023
Visit Reason
A complaint investigation was conducted on July 31, 2023, to determine if Monroe Manor was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, concluding on July 31, 2023, with violations substantiated as identified in SOD #8ONJ11.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency (SOD #8ONJ11), issuance of a Notice of Violation, and imposition of corrective orders and forfeiture.
Report Facts
Forfeiture amount: 2050
Reduced forfeiture amount: 1332.5
Forfeiture amount: 1050
Forfeiture amount: 1000
Compliance timeframe: 45
Investigation report submission timeframe: 14
Notification timeframe: 7
Payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William R. Gardner | 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: 56
Capacity: 82
Deficiencies: 6
Date: Jul 19, 2023
Visit Reason
Surveyors investigated 10 complaints at Monroe Manor, collecting data through 07/31/2023, focusing on allegations of abuse, neglect, misappropriation of property, and resident care concerns.
Complaint Details
The visit was complaint-related, investigating 10 complaints with 7 substantiated. Issues included misappropriation of resident funds, failure to investigate and report incidents, failure to notify residents/legal representatives, improper use of restraints, mishandling of resident funds, and failure to implement individual service plans.
Findings
Six violations were identified, including failure to investigate misappropriation of resident funds, failure to report incidents to law enforcement, failure to notify residents or legal representatives about missing funds, improper use of physical restraints, failure to maintain resident funds in interest-bearing accounts, and failure to implement individual service plans resulting in resident falls and unsanitary conditions.
Deficiencies (6)
Provider did not complete an investigation of misappropriation of property when resident funds were discovered missing from the safe.
Provider did not report two incidents of misappropriation of property to law enforcement when significant money was missing from resident trust accounts.
Provider did not notify residents or their legal representatives for two incidents when money was found missing from resident trust accounts.
Provider did not ensure Resident 1 was free from physical restraint; wheelchair brake was locked restricting mobility without approved authorization.
Provider did not ensure resident funds in excess of $200 were kept in an interest-bearing account in the resident's name.
Provider did not ensure each resident's individual service plan was implemented as written, resulting in Resident 1's fall with injury and Resident 2's unsanitary conditions and lack of safety checks.
Report Facts
Number of complaints investigated: 10
Number of substantiated complaints: 7
Number of violations identified: 6
Amount of missing resident funds: 2930
Facility licensed capacity: 82
Resident census: 56
Resident trust account balances: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Human Resource Manager C | Human Resource Manager | Interviewed regarding missing resident funds and lack of investigation. |
| Receptionist J | Receptionist | Responsible for resident trust accounts; lost safe keys; involved in missing funds incidents. |
| Nurse Manager B | Nurse Manager | Interviewed about missing funds and resident care; confirmed no investigation and no police contact. |
| General Manager A | General Manager | Interviewed about missing funds, audits, and law enforcement contact decisions. |
| Licensee E | Licensee | Replaced missing resident funds; decided against police reporting; involved in resident trust fund management. |
| Officer L | Police Officer | Interviewed regarding police contact; confirmed no reports filed for missing funds. |
| Caregiver F | Caregiver | Observed locking Resident 1's wheelchair brake, restricting mobility. |
| Caregiver G | Caregiver | Observed interacting with Resident 1 during restraint incident. |
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