Inspection Reports for New Perspective Senior Living | West Bend

WI, 53095

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 4.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

2% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/year

Deficiencies per year

8 6 4 2 0
2023
2024
2025

Census

Latest occupancy rate 34 residents

Based on a March 2025 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Census over time

20 40 60 80 Mar 2023 Jan 2024 Feb 2024 May 2024 Aug 2024 Mar 2025
Inspection Report Follow-Up Census: 34 Deficiencies: 0 Mar 27, 2025
Visit Reason
A verification visit was conducted on 03/27/2025 for Statement of Deficiency IC9Q11 from 05/09/2024 and also for SOD 2FY311 to verify correction of previous deficiencies.
Findings
All previous deficiencies identified in prior surveys have been corrected as a result of this verification visit.
Report Facts
Revisit fee: 200
Inspection Report Complaint Investigation Census: 36 Deficiencies: 0 Aug 14, 2024
Visit Reason
Surveyor conducted 2 complaint investigations and a verification visit at New Perspective - West Bend, a Residential Care Apartment Complex (RCAC) in West Bend.
Findings
No deficiencies were identified. Two of the two complaints were unsubstantiated. A previous Statement of Deficiency dated 02/09/2024 was corrected.
Complaint Details
Two complaints were investigated and both were found to be unsubstantiated.
Report Facts
Revisit fee: 200
Inspection Report Complaint Investigation Deficiencies: 0 May 9, 2024
Visit Reason
A Complaint Investigation and Self Report Review were conducted on May 9, 2024, to determine if New Perspective – West Bend was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #IC9Q11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, establishing grounds for enforcement action and requiring the licensee to comply with all applicable requirements within 45 days.
Complaint Details
The visit was complaint-related, involving a Complaint Investigation and Self Report Review to assess compliance with regulatory requirements. Specific substantiation status is not stated.
Report Facts
Inspection fee: 200 Compliance timeframe: 45 Appeal timeframe: 10 Posting duration: 90
Employees Mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter.
Vicky WittmanAssisted Living Regional DirectorContact person for questions about the letter.
Inspection Report Complaint Investigation Census: 30 Deficiencies: 2 May 9, 2024
Visit Reason
Surveyor conducted 2 complaint investigations and a self-report review at New Perspective-West Bend following complaints about residents not receiving medications and concerns related to resident care and documentation.
Findings
Two deficiencies were identified: one related to a resident missing prescribed medications due to unavailability and lack of follow-up, and another related to incomplete resident record documentation following multiple falls resulting in serious injury. One complaint was substantiated and one was unsubstantiated.
Complaint Details
Two complaint investigations were conducted; one complaint was substantiated regarding medication administration issues, and one complaint was unsubstantiated. The self-report review also resulted in a deficiency related to resident record maintenance.
Deficiencies (2)
Description
Resident 2 missed 4 doses of prescribed Guaifenesin medication during December 2023-January 2024 due to medication unavailability and lack of follow-up with the pharmacy.
Resident 1's record did not include documentation to accurately describe condition changes and vital checks following multiple falls within 24 hours, including an intracranial bleed and hospitalization.
Report Facts
Missed medication doses: 4 Falls: 3 Vital checks frequency: 12 Blood pressure reading: 190
Employees Mentioned
NameTitleContext
Nurse BAcknowledged medication unavailability and missing vital checks documentation.
Nurse CObserved Resident 1's condition change and documented late entries; involved in communication with legal representative and OT.
Administrator AInterviewed regarding missing documentation in Resident 1's record.
Inspection Report Complaint Investigation Deficiencies: 0 Feb 9, 2024
Visit Reason
A Complaint Investigation was conducted on February 9, 2024, for New Perspective – West Bend to determine if the facility 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 # FIW911), imposition of a forfeiture totaling $1,600, and issuance of special orders requiring corrective actions to ensure resident safety and compliance.
Complaint Details
The complaint investigation concluded that the facility was not in substantial compliance with applicable statutes and administrative codes, leading to issuance of SOD # FIW911 and enforcement actions including forfeiture and special orders.
Report Facts
Forfeiture amount: 1600 Reduced forfeiture amount: 1040 Forfeiture amount: 600 Forfeiture amount: 1000 Compliance timeframe: 45 Notification timeframe: 7 Payment timeframe: 10
Employees Mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Vicky WittmanAssisted Living Regional DirectorContact person for questions about the letter
Inspection Report Complaint Investigation Census: 31 Capacity: 60 Deficiencies: 2 Feb 9, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a report that Resident 1 was found in distress and potential neglect by local emergency services after calling 911 due to inability to find staff.
Findings
The provider failed to have adequate staff present to meet resident needs, resulting in Resident 1 being found alone, distressed, and in pain by emergency personnel. Staff did not respond promptly to alarms, and the provider did not immediately investigate or report the incident as required. The investigation was incomplete and delayed, and the provider submitted a late self-report that omitted critical details.
Complaint Details
The complaint was substantiated and resulted in 2 deficient practices. Resident 1 was found in distress by emergency services after calling 911 due to inability to find staff. The provider did not investigate or report the incident timely and failed to ensure adequate staffing.
Deficiencies (2)
Description
Failure to immediately take steps to protect residents or conduct an investigation when local police reported potential abuse and/or neglect of Resident 1.
Insufficient staffing to meet resident needs, resulting in inability to promptly respond to Resident 1's distress and alarms.
Report Facts
Resident census: 31 Total licensed capacity: 60 Time staff not located: 30 Time staff not located: 40 Number of residents requiring 2 assist: 12
Employees Mentioned
NameTitleContext
Executive Director EExecutive DirectorAcknowledged failure to report and investigate, communicated with police and staff, responsible for self-report submission
Caregiver FCaregiverNamed in findings for not responding promptly to alarms and being unaware of Resident 1's distress
Caregiver GCaregiverNamed in findings for not responding promptly to alarms and being unaware of Resident 1's distress
Wellness Director IWellness DirectorInterviewed regarding staffing and incident details
Manager KCare Team ManagerResponsible for staff follow-up and education, did not complete follow-up after incident
Officer APolice OfficerResponded to 911 call, documented incident and staff absence
Keyholder DContacted by police and Executive Director, involved in communication about incident
POA HPower of AttorneyResident's legal representative, not informed timely about incident
Inspection Report Complaint Investigation Deficiencies: 1 Jan 16, 2024
Visit Reason
The inspection was conducted as a complaint investigation to determine if New Perspective – West Bend was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #2FY311) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements to protect resident health, safety, and rights, including developing corrective measures and providing staff training. A forfeiture of $400 was imposed for the violations.
Complaint Details
The visit was a complaint investigation concluded on January 16, 2024, to determine compliance with applicable statutes and codes. The Department found violations and issued a Statement of Deficiency.
Deficiencies (1)
Description
Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #2FY311
Report Facts
Forfeiture amount: 400 Reduced forfeiture amount: 260 Compliance timeframe: 45 Forfeiture payment timeframe: 10
Inspection Report Complaint Investigation Census: 32 Deficiencies: 3 Jan 16, 2024
Visit Reason
Surveyor completed a complaint investigation at New Perspectives - West Bend, a CBRF, due to allegations that residents did not receive assistance with personal care needs as required.
Findings
The investigation identified three deficiencies including inadequate assistance with personal care such as toileting and feeding due to staffing shortages, failure to document changes in resident health conditions including illness and skin concerns, and failure of an employee to follow proper hand hygiene procedures during feeding assistance.
Complaint Details
The complaint was substantiated. The investigation confirmed residents did not receive required personal care assistance, and documentation of health changes was lacking.
Deficiencies (3)
Description
Residents did not receive assistance with personal care needs including toileting and feeding as required by their individual service plans due to staffing shortages.
Provider failed to document changes in resident health status, including illness symptoms and skin concerns, in resident records.
An employee was observed not performing hand hygiene between assisting multiple residents with feeding, violating infection control standards.
Report Facts
Deficiencies identified: 3 Residents requiring 2-person assist and lift: 13 Staffing patterns: 2 Residents observed needing feeding assistance: 5 Residents with loose stools and/or vomiting: 11
Employees Mentioned
NameTitleContext
Caregiver CInterviewed about difficulties providing toileting and feeding assistance due to staffing shortages
Caregiver DInterviewed about staffing challenges impacting toileting and feeding assistance
Caregiver BInterviewed about toileting and feeding assistance challenges and resident skin concerns
Caregiver EObserved not performing hand hygiene between feeding residents; interviewed about feeding assistance and hand hygiene practices
Caregiver FInterviewed about feeding assistance and medication administration
Private Duty Caregiver HProvided feeding assistance to Resident 6 and others
Executive Director AExecutive DirectorInterviewed regarding personal care concerns, staffing, and documentation issues
Health and Wellness Director GHealth and Wellness DirectorInterviewed regarding personal care concerns, staffing, and documentation issues
Inspection Report Re-Inspection Deficiencies: 0 Sep 6, 2023
Visit Reason
Surveyor conducted a verification visit to New Perspective-West Bend to confirm correction of previous deficiencies.
Findings
All previous deficiencies were corrected and no deficiencies were identified during this visit.
Report Facts
Revisit fee: 200
Inspection Report Abbreviated Survey Deficiencies: 0 Mar 15, 2023
Visit Reason
An Abbreviated Survey was conducted on March 15, 2023, by the Division of Quality Assurance, Bureau of Assisted Living, to determine if New Perspective - West Bend was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #HUGG11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, indicating noncompliance with regulatory requirements for the facility's administration and operation.
Report Facts
Compliance timeframe: 45 Inspection fee: 200 Appeal timeframe: 10
Employees Mentioned
NameTitleContext
Kathleen D. LyonsInterim Assisted Living DirectorSigned the notice letter
Vicky WittmanAssisted Living Regional DirectorContact person for questions about the letter
Inspection Report Abbreviated Survey Census: 29 Capacity: 60 Deficiencies: 6 Mar 13, 2023
Visit Reason
An abbreviated licensure survey was conducted at New Perspective - West Bend to assess compliance with regulatory requirements and identify deficiencies.
Findings
Six deficiencies were identified including failure to ensure employee communicable disease screening, inadequate continuing education for staff, personal care services not supporting resident independence, food safety violations, unclean and odorous resident rooms, and lack of approval for horizontal evacuation in the emergency plan.
Deficiencies (6)
Description
Failure to ensure 1 of 2 employees had been screened for communicable disease including tuberculosis within 90 days before employment.
Caregiver C did not receive at least 15 hours of required continuing education in 2021 and 2022.
Personal care services were not designed and provided to allow Resident 1 and Resident 2 to increase or maintain independence, with documented long response times to call lights.
Food safety violations including undated and uncovered food items in refrigerator and freezer, dirty kitchen surfaces, and mold in walk-in cooler.
Resident rooms were not clean and free from odors; laundry baskets were overflowing and odors of urine were noted in multiple resident rooms.
Horizontal evacuation was used in the emergency plan without Department approval, and fire drills did not include actual evacuation of residents.
Report Facts
Deficiencies identified: 6 Resident call light response times: 14 Resident call light events: 33 Licensed capacity: 60 Current census: 29
Employees Mentioned
NameTitleContext
Caregiver BNamed in deficiency for failure to have TB test within 90 days before employment.
Caregiver CNamed in deficiency for inadequate continuing education hours in 2021 and 2022.
Executive Director AExecutive DirectorInterviewed regarding multiple deficiencies including TB screening, continuing education, call light response times, food safety, laundry concerns, and horizontal evacuation approval.

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