Deficiencies (last 3 years)
Deficiencies (over 3 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
270% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
29 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
Complaint Investigation
Deficiencies: 1
Sep 17, 2025
Visit Reason
A complaint investigation was conducted on 09/17/2025 to determine if New Perspective Waukesha was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #3WK911) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a forfeiture of $330.00 imposed on the licensee.
Complaint Details
The complaint investigation concluded that the facility was not in substantial compliance with applicable statutes and administrative codes, leading to issuance of a Statement of Deficiency and enforcement action.
Deficiencies (1)
| Description |
|---|
| Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #3WK911 |
Report Facts
Forfeiture amount: 330
Reduced forfeiture amount: 214.5
Forfeiture payment timeframe: 10
Compliance timeframe: 45
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: 29
Deficiencies: 1
Sep 3, 2025
Visit Reason
On 09/03/2025, the Bureau of Assisted Living, Southern Regional Office, conducted a complaint investigation at New Perspective Waukesha, a community-based residential facility (CBRF) located in Waukesha, WI.
Findings
As a result of the survey, 1 deficiency was identified, which is a repeat deficiency related to residents not receiving medications as prescribed. The complaint was substantiated.
Complaint Details
The complaint was substantiated. The investigation found that Resident 1 did not receive prescribed medications as required, with medication administration records showing multiple missed doses and inconsistent documentation and communication regarding medication refills.
Deficiencies (1)
| Description |
|---|
| Provider did not ensure that Resident 1 received prescribed medications carbidopa/levodopa on 7 occasions and duloxetine on at least 6 occasions as prescribed by the practitioner. |
Report Facts
Deficiencies identified: 1
Census: 29
Missed medication administrations: 7
Missed medication administrations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health Wellness Director B | Registered Nurse | Reported medication reorder and follow-up process; interviewed by surveyor regarding medication issues |
| Caregiver C | Reported process for obtaining medication refills and communication with Health Wellness Director B | |
| Caregiver D | Reported on medication passers notifying Health Wellness Director B about low medications | |
| Executive Director A | Executive Director | Interviewed about medication supply and refill process |
Inspection Report
Follow-Up
Census: 36
Deficiencies: 0
Jul 21, 2025
Visit Reason
Surveyor conducted a verification visit to New Perspective Waukesha to verify correction of previously identified deficiencies.
Findings
No deficiencies were identified during the visit. The previously cited Statement of Deficiency XB9111 dated 02/17/2025 was corrected.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Census: 31
Capacity: 60
Deficiencies: 3
Feb 17, 2025
Visit Reason
The survey was conducted from 02/06/2025 to 02/17/2025 to investigate four complaints alleging failure to notify legal representatives of incidents, medication administration errors, and inadequate behavior management at New Perspective Waukesha, a CBRF.
Findings
Three deficiencies were identified: failure to immediately notify a resident's legal representative of an incident, failure to ensure residents received medications as prescribed including missed doses and improper timing, and failure to manage aggressive behaviors of a resident resulting in hospitalization and discharge to another facility.
Complaint Details
Four complaints were investigated and all four were substantiated. Complaints included failure to notify legal representatives, medication administration errors, and inadequate behavior management.
Deficiencies (3)
| Description |
|---|
| Failure to immediately notify Resident 1's legal representative of an incident affecting the resident's physical or mental condition. |
| Failure to ensure 2 of 3 residents reviewed received their medications as prescribed, including missed doses due to pharmacy delays and medications administered outside prescribed intervals. |
| Failure to manage Resident 1's aggressive behaviors adequately, lacking documented behavior assessments or interventions, resulting in hospitalization and discharge. |
Report Facts
Deficiencies identified: 3
Residents reviewed for medication: 3
Residents with medication issues: 2
Facility licensed capacity: 60
Resident census: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding follow-up on incident notification and behavior management; acknowledged lack of documentation and issues with Resident 1's behavior management. |
| Regional RN D | Regional Registered Nurse | Interviewed regarding incident notification, medication administration, and behavior management; unable to provide additional documentation or follow-up. |
| RN F | Registered Nurse | Interviewed regarding medication administration issues and pharmacy delays. |
| Caregiver B | Caregiver | Interviewed about Resident 1's aggressive behaviors and interventions used. |
| Caregiver C | Caregiver | Interviewed about Resident 1's behaviors and interventions. |
| Director of Operations E | Director of Operations | Interviewed regarding behavior management of Resident 1; acknowledged limited interventions and lack of documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 6, 2025
Visit Reason
A complaint investigation was conducted to determine if New Perspective Waukesha was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #XB9111) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in an order to comply with requirements and corrective measures including behavior management procedures. A forfeiture of $1900 was imposed for the violations.
Complaint Details
The investigation was complaint-driven and concluded on February 6, 2025. The facility was found not in substantial compliance, leading to issuance of SOD #XB9111.
Deficiencies (1)
| Description |
|---|
| Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #XB9111 |
Report Facts
Forfeiture amount: 1900
Reduced forfeiture amount: 1235
Forfeiture component: 900
Forfeiture component: 1000
Compliance timeframe: 45
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
Enforcement
Deficiencies: 0
Dec 3, 2024
Visit Reason
A standard survey and verification visit was conducted on December 3, 2024, to determine if New Perspective Waukesha 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 #BKSP12 and imposition of a total forfeiture of $1800.00. A $200 inspection fee for a revisit to verify correction of prior violations was also assessed.
Report Facts
Forfeiture amount: 1800
Reduced forfeiture amount: 1170
Forfeiture amount for tag N 277: 200
Forfeiture amount for tag N 381: 1600
Revisit 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 |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Routine
Census: 23
Deficiencies: 2
Dec 3, 2024
Visit Reason
The Bureau of Assisted Living conducted 2 verification visits and a standard survey at New Perspective Waukesha, a CBRF, to assess compliance with regulatory requirements.
Findings
Two deficiencies were identified, both repeat deficiencies related to continuing education requirements for caregivers and failure to complete assessments after resident falls. The provider was assessed a $200 revisit fee under statutory provisions.
Deficiencies (2)
| Description |
|---|
| The provider did not ensure 1 of 1 caregivers received at least 15 hours of continuing education per calendar year as required. |
| The provider did not ensure assessments were completed after changes in condition for 2 of 2 residents who sustained multiple falls, with inadequate post-fall evaluations. |
Report Facts
Revisit fee: 200
Number of deficiencies identified: 2
Continuing education hours documented: 3.5
Continuing education hours documented: 12.75
Falls sustained by Resident 2: 15
Post-fall evaluations completed for Resident 2: 4
Falls sustained by Resident 3: 7
Post-fall evaluations completed for Resident 3: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver J | Named in continuing education deficiency | |
| Executive Director H | Executive Director | Interviewed regarding continuing education documentation and fall assessments |
| Regional Director of Clinical Operations I | Regional Director of Clinical Operations | Interviewed regarding fall assessments and documentation |
| Director of Operations G | Director of Operations | Participated in review of fall concerns with surveyors |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 2
Jul 30, 2024
Visit Reason
The inspection was conducted from 07/29/2024 to 07/30/2024 as a complaint investigation triggered by two complaints regarding resident care and safety at New Perspective Waukesha, a CBRF in Waukesha.
Findings
Two deficiencies were identified, including a repeat deficiency. One deficiency involved failure to safeguard residents from environmental hazards, resulting in Resident 1's fall from a raised bed causing fatal injuries. The second deficiency involved failure to provide timely personal care services, with Resident 1's requests for assistance not responded to for over 60 minutes.
Complaint Details
Two complaints were investigated and both were substantiated. The investigation included interviews and record reviews related to Resident 1's fall and delayed response to call lights. Hospice notes and call light response times documented long delays, some exceeding 160 minutes, in responding to Resident 1's calls for assistance.
Deficiencies (2)
| Description |
|---|
| Failure to ensure residents were safeguarded from environmental hazards; Resident 1's bed was left in a raised position resulting in injuries leading to death after a fall. |
| Failure to provide personal care services timely; Resident 1's requests for assistance were not responded to for greater than 60 minutes. |
Report Facts
Census: 23
Deficiencies identified: 2
Call light response times (minutes): 86
Call light response times (minutes): 63
Call light response times (minutes): 52
Call light response times (minutes): 115
Call light response times (minutes): 162
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Provided Resident 1's record and confirmed bed elevation policy | |
| Administrator A | Administrator | Interviewed regarding Resident 1's fall and call light response times |
| Caregiver C | Caregiver | Interviewed about Resident 1's fall and bed position |
| Caregiver D | Caregiver | Interviewed about call light system and response |
| Caregiver E | Caregiver | Interviewed about Resident 1's fall and call light response |
| Care Team Manager F | Care Team Manager | Responsible for auditing call light response times |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 30, 2024
Visit Reason
A complaint investigation was conducted to determine if New Perspective Waukesha 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 BKSP11 and issuance of a Notice of Violation with orders to comply and corrective actions required.
Complaint Details
Complaint investigation concluded on July 30, 2024, to determine substantial compliance with applicable statutes and codes. Violations were substantiated as per the issuance of the Statement of Deficiency BKSP11.
Deficiencies (1)
| Description |
|---|
| Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in Statement of Deficiency BKSP11 |
Report Facts
Forfeiture amount: 1500
Reduced forfeiture amount: 975
Forfeiture amount: 1000
Forfeiture amount: 500
Compliance timeframe: 45
Payment timeframe: 10
Appeal timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hillary Holman | 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: 25
Deficiencies: 0
Jun 20, 2024
Visit Reason
Surveyor conducted a complaint investigation at New Perspective Waukesha on 2024-06-18.
Findings
No deficiencies were identified; the complaint was unsubstantiated.
Complaint Details
Complaint investigation conducted on 2024-06-18; complaint was unsubstantiated.
Notice
Deficiencies: 0
May 28, 2024
Visit Reason
A complaint investigation and verification visit was conducted on May 28, 2024, to determine if New Perspective Waukesha 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 Notice of Violation, an Order to Comply with Requirements, Special Orders to improve staffing and food safety procedures, and a total forfeiture of $2050.00 imposed. A $200 inspection fee for a verification visit was also assessed.
Complaint Details
The visit was complaint-related, conducted to verify compliance with applicable statutes and codes. Specific substantiation status is not stated.
Report Facts
Forfeiture amount: 2050
Reduced forfeiture amount: 1332.5
Forfeiture amounts by tag: 500
Forfeiture amounts by tag: 600
Forfeiture amounts by tag: 500
Forfeiture amounts by tag: 150
Forfeiture amounts by tag: 300
Inspection fee: 200
Compliance timeframe: 45
Notification timeframe: 7
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: 26
Capacity: 60
Deficiencies: 5
May 28, 2024
Visit Reason
Surveyor conducted two verification visits and a complaint investigation at New Perspective Waukesha, a CBRF, due to concerns including a complaint about inadequate treatment following a resident fall and verification of compliance with previous special orders.
Findings
Five deficiencies were identified, including repeat deficiencies related to prompt and adequate treatment, adequate staffing, and food safety. The complaint regarding inadequate treatment of Resident 16 after a fall was substantiated. Additional findings included inadequate staffing during overnight shifts, unsanitary kitchen conditions, and improperly stored food items.
Complaint Details
The complaint was substantiated. Resident 16 did not receive prompt and adequate treatment after a fall on 03/02/2024, with delayed emergency room transfer until approximately 6:00 p.m. despite signs of severe headache, convulsion, and pain.
Deficiencies (5)
| Description |
|---|
| Failure to provide prompt and adequate treatment to Resident 16 who sustained a fall and hip fracture but was not sent to the emergency room until approximately 6:00 p.m. |
| Inadequate staffing with only one staff member present during a night shift when a resident required assistance of two and multiple overnight shifts without a caregiver able to administer medications. |
| Equipment and utensils in the kitchen and memory care were not stored in a clean manner and were not maintained in good repair, including hardened food residues and standing water. |
| Food safety violations including expired, unsealed, unlabeled, and undated food items stored in refrigerators and freezers. |
| Failure to comply with special orders requiring provision of documentation to residents and case managers regarding previous statements of deficiency. |
Report Facts
Deficiencies identified: 5
Revisit fee: 200
Residents present: 26
Licensed capacity: 60
Overnight shifts without medication-trained staff: 4
Hours with only one caregiver present: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Operations CC | Acknowledged lack of documentation for special orders compliance and was involved in discussions about kitchen conditions and staffing concerns. | |
| Director of Nursing AA | Interviewed regarding Resident 16's delayed treatment and staffing concerns; agreed with surveyor's findings. | |
| Care Team Manager BB | Confirmed staffing shortages during overnight shifts. | |
| Cook Z | Observed kitchen conditions and acknowledged concerns about cleanliness and food storage. | |
| Caregiver X | Reported use of plastic utensils due to insufficient metal utensils in memory care kitchenette. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 23, 2024
Visit Reason
Surveyor conducted a complaint investigation at New Perspective Waukesha, a CBRF located in Waukesha, WI.
Findings
As a result of the investigation, zero violations of Chapter DHS 83 were issued and the complaint was unsubstantiated.
Complaint Details
The complaint was unsubstantiated.
Report Facts
Violations issued: 0
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 7, 2024
Visit Reason
A complaint investigation and verification visit was conducted to determine if New Perspective Waukesha was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #IIF413) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation, Orders to Comply, Special Orders, and a forfeiture of $1,000. A verification visit was also conducted to determine if prior violations were corrected, resulting in a $200 inspection fee.
Complaint Details
The visit was complaint-related, conducted to verify compliance with statutory and administrative requirements. The Department found violations and issued enforcement actions including forfeiture.
Deficiencies (1)
| Description |
|---|
| Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #IIF413 |
Report Facts
Forfeiture amount: 1000
Forfeiture amount: 550
Forfeiture amount: 450
Reduced forfeiture amount: 650
Inspection fee: 200
Compliance timeframe: 45
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: 24
Capacity: 60
Deficiencies: 5
Jan 25, 2024
Visit Reason
Surveyor conducted a verification visit and complaint investigation at New Perspective Waukesha following a concern alleging a resident had a choking episode which resulted in death.
Findings
Five deficiencies were identified including repeat violations related to death reporting, documentation, pre-admission assessments, individual service plan implementation, and equipment storage and cleanliness. The complaint was substantiated and a $200 revisit fee is being assessed.
Complaint Details
Complaint was substantiated. The investigation involved review of resident records, interviews with administrators and caregivers, and observation of facility practices related to a choking incident resulting in resident death.
Deficiencies (5)
| Description |
|---|
| Death reporting related to accident or injury; provider did not report resident death within 3 days as required. |
| Documentation requirements for written report; provider did not have a written report for choking incident including required details. |
| Pre-admission and ongoing assessments; provider did not assess resident's needs and condition related to choking risk. |
| Implementation of individual service plan; provider did not follow resident's prescribed minced moist diet resulting in choking episodes and death. |
| Equipment and utensils not stored in a clean manner; kitchen had water leaks, grease stains, and food debris on equipment and floors. |
Report Facts
Deficiencies identified: 5
Revisit fee: 200
Resident census: 24
Total licensed capacity: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator T | Administrator | Interviewed regarding resident choking incident and facility protocols |
| Caregiver W | Caregiver | Interviewed about resident choking incident and feeding practices |
| Caregiver X | Caregiver | Interviewed about resident choking incident and feeding practices |
| Caregiver Y | Caregiver | Interviewed about kitchen awareness of dietary restrictions and food service |
| Cook U | Cook | Interviewed about kitchen conditions and equipment maintenance |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 2, 2023
Visit Reason
A complaint investigation and verification visit was conducted on November 2, 2023, to determine if New Perspective Waukesha was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #PHBR12) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation and an imposed forfeiture of $500. The licensee was ordered to comply with requirements immediately and to provide documentation of compliance within specified timeframes.
Complaint Details
The visit was complaint-related, conducted to verify compliance following a complaint investigation. The Department found violations substantiated as detailed in SOD #PHBR12.
Deficiencies (1)
| Description |
|---|
| Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as detailed in Statement of Deficiency #PHBR12 |
Report Facts
Forfeiture amount: 500
Reduced forfeiture amount: 325
Inspection fee: 200
Compliance timeframe: 45
Notification timeframe: 7
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 and compliance |
Inspection Report
Follow-Up
Census: 26
Capacity: 60
Deficiencies: 3
Nov 2, 2023
Visit Reason
The surveyor conducted a verification visit to New Perspective Waukesha to assess compliance with prior deficiencies and verify correction of previous violations.
Findings
Three deficiencies were identified, including repeat violations related to inadequate staffing to meet resident needs, failure to ensure prompt treatment, and medication storage issues. Specific findings included insufficient staff on 3rd shifts, delayed response times to resident call pendants, and an unlocked medication cart.
Deficiencies (3)
| Description |
|---|
| Failure to ensure resident right to prompt and adequate treatment; specifically, lack of two staff to meet Resident 2's needs and unqualified caregiver passing medications on 3rd shift on 10/20/2023. |
| Insufficient number of employees on a 24-hour basis to meet resident needs, evidenced by multiple call pendant/emergency pull cord wait times exceeding 20 minutes for Residents 3 and 4. |
| Medications administered by the facility were not kept locked; medication cart was observed unlocked from 10:04 AM to 10:47 AM on 10/30/2023. |
Report Facts
Revisit fee: 200
Resident call pendant wait times exceeding 20 minutes: 4
Resident call pendant wait times exceeding 20 minutes: 23
Census: 26
Total licensed capacity: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse J | Medication passer | Named in medication storage deficiency for leaving medication cart unlocked |
| Administrator H | Administrator | Interviewed regarding staffing schedules and exit conference for findings |
Inspection Report
Enforcement
Deficiencies: 0
Sep 13, 2023
Visit Reason
A verification visit was conducted on 09/13/2023 to determine if New Perspective Waukesha was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities (CBRF).
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency (SOD #IIF412) and imposed a forfeiture of $500.00. The licensee is ordered to comply with all requirements within 45 days and is subject to inspection fees and enforcement actions.
Report Facts
Forfeiture amount: 500
Reduced forfeiture amount: 325
Inspection fee: 200
Compliance timeframe: 45
Forfeiture payment timeframe: 10
Revisit fee 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
Follow-Up
Census: 26
Deficiencies: 5
Sep 13, 2023
Visit Reason
Surveyors conducted a verification visit at New Perspective Waukesha to assess correction of previously identified deficiencies.
Findings
Five deficiencies were identified, four of which were repeat deficiencies from a prior statement dated 04/20/2023. Deficiencies involved incomplete comprehensive individual service plans for residents, food safety violations related to unsanitary kitchen conditions, and environmental issues including burned out light bulbs and damaged resident room features.
Deficiencies (5)
| Description |
|---|
| Comprehensive Individualized Service Plan not ensured for 1 of 1 resident (Resident 13) including specific needs and methods for delivering care. |
| Service plans not updated annually or on changes for 1 of 1 resident (Resident 7), missing interventions/guidelines regarding behaviors. |
| Food safety: Provider did not ensure food was prepared and stored in a sanitary manner; stove and oven were very dirty and food was stored on the floor of walk-in cooler and freezer. |
| Environment not safe, clean, and comfortable; 14 burned out light bulbs in dining room, dirty steamer basin, damaged bathroom doorway and door frame, missing baseboard trim, and other maintenance issues. |
| Resident 2's toilet seat broken at hinge causing movement; toilet paper dispenser missing rod; towel holder missing rod; Resident 3, 9, and 14 bedrooms had carpet stains and laundry baskets with urine-like scent. |
Report Facts
Deficiencies identified: 5
Repeat deficiencies: 4
Census: 26
Burned out light bulbs: 14
Two liter soda bottles stored on floor: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Discussed concerns and acknowledged deficiencies with surveyors |
| Caregiver O | Observed and interviewed regarding resident behaviors and care | |
| Care Team Manager C | Care Team Manager | Interviewed regarding resident fall risk and behaviors |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 29, 2023
Visit Reason
A complaint investigation was conducted to determine if New Perspective Waukesha was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #PHBR11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a forfeiture of $1000 imposed on the licensee for noncompliance.
Complaint Details
The investigation was complaint-driven and concluded on June 29, 2023. The Department determined violations existed and issued enforcement actions including a forfeiture.
Deficiencies (1)
| Description |
|---|
| Violation of Wis. Admin. Code 83.32(3)(i) as cited in SOD #PHBR11 |
Report Facts
Forfeiture amount: 1000
Reduced forfeiture amount: 650
Forfeiture payment deadline: 10
Compliance timeframe: 45
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: 22
Capacity: 60
Deficiencies: 1
Jun 29, 2023
Visit Reason
Surveyor conducted a complaint investigation at New Perspective Waukesha following a complaint alleging concerns about the lack of a medication passer on the 3rd shift and inadequate pain management for a hospice patient.
Findings
One deficiency was identified where the provider did not ensure residents received prompt and adequate treatment, specifically Resident 1 did not receive adequate pain management due to unavailable physician-ordered medications and lack of trained caregiver to administer medications.
Complaint Details
The complaint was substantiated. The investigation revealed staffing issues including no medication passer on the night of 05/05/2023, resulting in family members having to obtain and administer medications. Facility staff and regional director acknowledged the staffing issues and delayed awareness of the problem until 05/06/2023.
Deficiencies (1)
| Description |
|---|
| Provider did not ensure residents received prompt and adequate treatment; Resident 1, a hospice patient, did not receive adequate pain management and care when physician ordered medications were not available and a trained caregiver was not available to pass medications. |
Report Facts
Licensed capacity: 60
Current census: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Sent text messages to family member about lack of medication passer and medication availability |
| Regional Director B | Regional Director | Interviewed by surveyor; confirmed staffing issues and medication administration problems |
| Social Worker G | Social Worker | Visited patient and family to provide emotional support during transition |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 0
May 3, 2023
Visit Reason
Surveyor conducted a complaint investigation at Perspective Living Waukesha on 05/03/2023.
Findings
No deficiencies were identified during the complaint investigation; the complaint was unsubstantiated.
Complaint Details
Complaint investigation was unsubstantiated with no deficiencies identified.
Report Facts
Census: 26
Inspection Report
Abbreviated Survey
Deficiencies: 2
Apr 20, 2023
Visit Reason
An abbreviated survey and complaint investigation was conducted to determine if New Perspective Waukesha 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 #IIF411 and imposed a total forfeiture of $2,320.00 for multiple violations related to staffing and operational requirements.
Complaint Details
The visit included a complaint investigation to determine compliance with applicable statutes and codes.
Deficiencies (2)
| Description |
|---|
| Failure to provide employees in sufficient numbers on a 24-hour basis to meet the needs of residents as required by Wis. Admin. Code § DHS 83.36(1)(a). |
| Violations identified under tags N396, N277, N381, N389, and N425 as detailed in SOD #IIF411. |
Report Facts
Forfeiture amount: 2320
Reduced forfeiture amount: 1508
Forfeiture breakdown: 320
Forfeiture breakdown: 600
Forfeiture breakdown: 600
Forfeiture breakdown: 600
Forfeiture breakdown: 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: 27
Capacity: 60
Deficiencies: 16
Apr 6, 2023
Visit Reason
On 04/06/2023, surveyors conducted a standard licensure survey and a complaint investigation at New Perspective Waukesha. The complaint was substantiated.
Findings
Sixteen deficiencies were identified including incomplete caregiver background checks, inadequate employee screening for communicable diseases, insufficient continuing education for staff, missing admission agreements, failure to provide written grievance summaries, incomplete resident assessments, inadequate staffing, improper medication administration documentation, unsafe oxygen storage, food safety violations, and environmental cleanliness issues.
Complaint Details
Complaint was substantiated. Complaints included concerns about resident care, medication administration errors, inadequate staffing, and environmental cleanliness. Family members reported issues with showering, medication availability, and response times to call lights.
Deficiencies (16)
| Description |
|---|
| Licensee did not ensure complete background checks were conducted for 2 of 3 employees reviewed. |
| Provider did not ensure documentation was obtained showing 2 of 3 employees were screened for communicable disease including tuberculosis within 90 days of employment. |
| Provider did not ensure 3 of 3 employees completed at least 15 hours of continuing education in 2022. |
| Provider did not have an admission agreement for Resident 4 that included individualized information regarding room rate and charges for services. |
| Provider did not ensure a written summary of grievances, including conclusions, was recorded and maintained. |
| Provider did not ensure an assessment of Resident 6's physical and mental condition was completed when there was a change in needs. |
| Provider did not ensure individual service plans (ISP) for Residents 2 and 7 were updated when there was a change in resident needs and abilities. |
| Provider did not ensure adequate staff numbers on a 24-hour basis to meet resident needs; staff reported long wait times and delayed care. |
| Provider did not ensure proper documentation of the Medication Administration Record (MAR) for Residents 1, 4, 7, and 11. |
| Provider did not ensure personal care services were provided to increase or maintain resident independence; Residents 5 and 7 did not receive scheduled assistance or showers. |
| Provider did not ensure hand washing procedures were followed by staff, including Med Technician P. |
| Provider did not ensure oxygen cylinders were stored in a secure manner; several cylinders in Resident 1's room were unsecured. |
| Provider did not make weekly menus available to residents and did not document deviations from planned menus. |
| Provider did not store food under sanitary conditions; observed moldy peaches, unsealed containers, and expired milk. |
| Provider did not ensure clothes dryers were properly vented and maintained; 4 dryers had vent tubing made of semi-rigid material. |
| Provider did not ensure the environment was safe, clean, and comfortable; resident rooms were not clean or comfortable with various sanitation issues. |
Report Facts
Deficiencies identified: 16
Census: 27
Total licensed capacity: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver D | Hired 06/15/2022; record did not include DOJ or IBIS letter at time of hire; missing TB screening documentation. | |
| Caregiver E | Hired 08/05/2021; record did not include DOJ or IBIS letter at time of hire; completed approximately 2 hours of continuing education in 2022. | |
| Caregiver C | Missing documentation for TB screening within 90 days of employment. | |
| Caregiver I | Observed preparing evening meal; resigned effective in 2 weeks. | |
| Caregiver M | Observed preparing evening meal; resigned effective in 2 weeks; reported staffing concerns. | |
| Administrator A | Administrator | Acknowledged concerns during exit conferences; interviewed multiple times regarding findings. |
| Accounting Manager G | Accounting Manager | Interviewed regarding Resident 4's fees and billing statements. |
| Care Team Manager C | Care Team Manager | Interviewed regarding Resident 7's care and service delivery. |
| Med Technician P | Med Technician | Observed not properly washing hands before medication administration; medication pass observed with multiple errors. |
| Maintenance Director B | Maintenance Director | Interviewed regarding dryer vents and maintenance issues. |
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