Deficiencies (last 2 years)
Deficiencies (over 2 years)
1.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
18 residents
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
Surveyor conducted 2 complaint investigations at Reflections at Moraine Ridge.
Complaint Details
Two complaints were investigated and found to be unsubstantiated.
Findings
No deficiencies were identified and the complaints were unsubstantiated.
Inspection Report
Follow-Up
Census: 15
Deficiencies: 0
Date: Apr 17, 2024
Visit Reason
Surveyors conducted a verification visit to Reflections at Moraine Ridge to verify correction of previous deficiencies.
Findings
All previous deficiencies were corrected and no new deficient practices were identified during the visit.
Report Facts
Revisit fee: 200
Notice
Deficiencies: 0
Date: Oct 18, 2023
Visit Reason
The document serves as a Notice of Violation and Order to Comply following a Standard Survey and Complaint Investigation conducted to determine if Reflections at Moraine Ridge was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department of Health Services found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83 at Reflections at Moraine Ridge, resulting in the issuance of Statement of Deficiency #TTM311 and an order to achieve and maintain substantial compliance within 45 days.
Report Facts
Days to achieve compliance: 45
Appeal filing period: 10
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter as Bureau of Assisted Living, Division of Quality Assurance. |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Routine
Census: 7
Deficiencies: 3
Date: Oct 18, 2023
Visit Reason
Surveyors conducted a standard licensure survey and one complaint investigation at Reflections At Moraine Ridge.
Complaint Details
Complaint investigation was conducted and substantiated regarding the unclean and odorous condition of Resident 1's room.
Findings
Three deficiencies were identified including unsafe and unclean living environment conditions, failure to maintain rooms free from odors, and lack of department approval for horizontal evacuation in the emergency plan. The complaint investigation was substantiated.
Deficiencies (3)
Laundry room had lint buildup on dryer vents creating fire hazards; emergency light malfunctioning; unsecured chemicals in kitchenette; no paper towels in common bathroom; common bathrooms lacked keyed locks.
Resident 1's room had a strong urine-like odor with soiled clothing present, indicating failure to keep rooms clean and free from odors.
Provider did not obtain Department approval before implementing horizontal evacuation in the emergency and disaster plan.
Report Facts
Deficiencies identified: 3
Census: 7
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