Inspection Reports for
Prairie Gardens
900 OKEEFFE AVE, SUN PRAIRIE, WI, 53590
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/year
Deficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
34 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Census: 34
Deficiencies: 0
Date: Jul 14, 2025
Visit Reason
Surveyor conducted a standard survey and two complaint investigations at Prairie Gardens, a CBRF in Sun Prairie from 07/08/2025 to 07/14/2025.
Complaint Details
Two complaints were investigated and both were found to be unsubstantiated.
Findings
No deficiencies were identified during the survey. Two of two complaints investigated were unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 22, 2024
Visit Reason
On 05/22/2024, the Bureau of Assisted Living, Southern Regional Office, conducted a verification visit at Prairie Gardens to follow up on previous deficiencies.
Findings
The results of the revisit are documented in the Statement of Deficiency for survey event XR2713.
Inspection Report
Follow-Up
Census: 38
Deficiencies: 0
Date: May 22, 2024
Visit Reason
The Bureau of Assisted Living, Southern Regional Office, conducted a verification visit for Statement of Deficiency (SOD) XR2712 dated 12/29/2023 and SOD ILNU11 dated 01/26/2024 at Prairie Gardens, a community-based residential facility (CBRF) in Sun Prairie, WI.
Findings
As a result of the survey, zero deficiencies were identified. All five deficiencies from SOD XR2712 and both deficiencies from SOD ILNU11 were corrected. A $200 revisit fee is being assessed under statutory provisions.
Report Facts
Revisit fee: 200
Deficiencies corrected: 7
Census: 38
Notice
Deficiencies: 1
Date: Jan 26, 2024
Visit Reason
A complaint investigation was conducted on 01/26/2024 to determine if Prairie Gardens was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
Complaint investigation concluded on 01/26/2024; violations substantiated as per Statement of Deficiency #ILNU11.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83 related to medication administration and management, resulting in a Statement of Deficiency and an imposed forfeiture.
Deficiencies (1)
Failure to comply with medication administration requirements including documentation, timely prescriptions, secure storage, monitoring, and disposal of medications.
Report Facts
Forfeiture amount: 400
Reduced forfeiture amount: 260
Days to comply: 45
Days to request extension: 10
Days to pay forfeiture: 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 regarding the notice. |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 2
Date: Jan 26, 2024
Visit Reason
The Bureau of Assisted Living conducted a complaint investigation at Prairie Gardens, a community-based residential facility, due to concerns about grievance procedures and medication administration.
Complaint Details
The complaint was substantiated. Concerns included failure to document grievance findings and conclusions, and medication administration errors involving Resident 1's Exelon patch and medication given to other residents.
Findings
Two deficiencies were identified, including a repeat deficiency related to grievance procedure documentation and concerns about medication administration errors involving Resident 1's Exelon patch and medication administration to other residents.
Deficiencies (2)
The provider did not provide a written summary of grievances, findings, conclusions, and actions taken to Resident 1's legal representative when two grievances were brought up.
The provider did not ensure that medication administration was provided to Resident 1 appropriate to his/her needs, including failure to discontinue old anticonvulsant medication prior to starting new medication and errors in administration of Exelon patches.
Report Facts
Deficiencies identified: 2
Grievances recorded: 2
Resident census: 41
Medication administration incidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manager C | Manager | Named in grievance procedure and medication administration findings |
| Director of Nursing B | Director of Nursing | Named in grievance procedure and medication administration findings |
| Administrator A | Administrator | Interviewed during complaint investigation |
| Pharmacy Technician G | Pharmacy Technician | Interviewed regarding medication refill and administration |
| Pharmacist H | Pharmacist | Interviewed regarding medication administration and patch application |
Inspection Report
Enforcement
Deficiencies: 2
Date: Dec 29, 2023
Visit Reason
A verification visit was conducted on 12/29/2023 to determine if Prairie Gardens was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities (CBRF). The Department issued a Statement of Deficiency (SOD) #XR2712 for violations found during this visit.
Findings
The Department found multiple violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83 related to medication administration, criminal background checks for employees, and other operational standards. The licensee was ordered to comply immediately and implement corrective measures within 45 days, including staff training and updating personnel records. A total forfeiture of $1,300 was imposed for the violations.
Deficiencies (2)
Failure to provide medication administration appropriate to the resident’s needs, specifically related to insulin management.
Non-compliance with criminal background check requirements for employees and contractors with direct resident contact.
Report Facts
Forfeiture amount: 1300
Reduced forfeiture amount: 845
Forfeiture breakdown: 150
Forfeiture breakdown: 400
Forfeiture breakdown: 200
Forfeiture breakdown: 150
Forfeiture breakdown: 400
Inspection fee: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the enforcement notice letter. |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Routine
Census: 41
Capacity: 47
Deficiencies: 5
Date: Dec 29, 2023
Visit Reason
On 12/27/2023, the Bureau of Assisted Living conducted a verification visit at Prairie Gardens, a community-based residential facility in Sun Prairie, WI, to assess compliance with regulatory requirements.
Findings
The survey identified 5 repeat deficiencies related to medication administration errors, unsecured medication storage, unsafe and unclean environment, and improper storage of toxic substances. The provider was assessed a $200 revisit fee under statutory provisions.
Deficiencies (5)
Provider did not ensure Resident 4 received all prescribed medications in correct dosages, including sliding scale insulin errors on 3 occasions.
Provider did not ensure medicine cabinets were locked; medication storage was unsecured and accessible.
Provider did not ensure the environment was safe, clean, and comfortable; observed rodent feces, missing light switch and outlet covers, unclean kitchen stove, and scuffed walls.
Provider did not ensure toxic substances such as cleaning compounds, polishes, and insecticides were labeled and stored in secure areas.
Provider did not ensure background checks were completed and final disposition of charges obtained for employees charged with crimes.
Report Facts
Deficiencies identified: 5
Revisit fee: 200
Census: 41
Total licensed capacity: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding medication errors, environment safety, and background check compliance. |
| Resident Manager F | Resident Manager | Interviewed regarding medication errors, environment safety, and background check compliance. |
| Caregiver C | Employee with background check showing charges of disorderly conduct and battery. | |
| Caregiver H | Employee with background check showing felony charge of substantial battery. | |
| Director of Nursing B | Director of Nursing | Potentially responsible for follow-up on background check information for Caregivers C and H. |
| Cook G | Cook | Observed kitchen stove condition and agreed it should be cleaned. |
Inspection Report
Enforcement
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
A standard survey was conducted on 08/02/2023 to determine if Prairie Gardens 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 #XR2711) and the imposition of a $200 forfeiture for noncompliance with regulatory requirements.
Report Facts
Forfeiture amount: 200
Reduced forfeiture amount: 130
Days to achieve compliance: 45
Days to pay forfeiture: 10
Days to request extension: 10
Days to request hearing: 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: 36
Capacity: 47
Deficiencies: 7
Date: Aug 2, 2023
Visit Reason
On 08/02/2023, the Bureau of Assisted Living, Southern Regional Office, conducted a standard licensing survey at Prairie Gardens, a community-based residential facility (CBRF) located in Sun Prairie, WI.
Findings
As a result of the survey, 7 deficiencies were identified including medication administration errors, unsecured medication storage, food safety violations, environmental safety issues, toxic substance storage concerns, and failure to ensure staff background checks compliance.
Deficiencies (7)
Provider did not ensure that 1 of 3 residents reviewed received all prescribed medications in the dosages as prescribed by a practitioner; Resident 4 received incorrect dosage of sliding scale insulin on 4 occasions from 07/11/2023 through 08/02/2023.
Provider did not ensure medications administered by the facility were kept locked; medication cabinets were unlocked with medication overflow observed.
Provider did not ensure all freezing units were maintained at 0°F or below; walk-in freezer near pantry did not work properly and held temperatures at 40°F and 50°F.
Provider did not ensure the environment was safe, clean, and comfortable; mouse droppings observed in cabinet under sink, rust on kitchen back door, exposed wires in hallway and stairway, thick dust in laundry room.
Provider did not ensure cleaning compounds, polishes, insecticides, and toxic substances were labeled and stored in a secure area; many areas with unsecured toxic substances observed.
Provider did not ensure solid core wood doors or equivalent fire resistive doors were provided at interior stair between basement and first floor; doors did not fully self-close and lock.
Provider did not ensure staff background checks were complete and compliant; Caregiver C had charges for disorderly conduct and battery but provider did not ensure every reasonable effort was made to obtain court documentation.
Report Facts
Deficiencies identified: 7
Census: 36
Total capacity: 47
Medication administration discrepancies: 4
Residents affected by medication storage overflow: 19
Employees reviewed for background checks: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding insulin administration discrepancies, medication storage overflow, freezer issues, environmental concerns, and staff background check compliance |
| Director of Nursing B | Director of Nursing | Interviewed regarding insulin administration discrepancies, medication storage overflow, freezer issues, environmental concerns, and staff background check compliance |
| Caregiver C | Caregiver | Subject of background check with charges for disorderly conduct and battery |
| Caregiver D | Caregiver | Observed during environmental inspection, reported door not fully closing in laundry room |
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