Inspection Reports for Riverview Village Senior Living

WI, 53051

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 6 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

30% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/year

Deficiencies per year

4 3 2 1 0
2023
2024
2025

Census

Latest occupancy rate 41 residents

Based on a September 2025 inspection.

Census over time

24 30 36 42 48 54 May 2023 Aug 2023 May 2024 Aug 2024 Feb 2025 Sep 2025

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Sep 3, 2025

Visit Reason
A verification visit and complaint investigation were conducted on September 3, 2025, at Riverview Village Senior Living to determine if the facility 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 to assess compliance. The Department found violations as detailed in SOD #XCD215 and imposed enforcement actions including forfeiture and inspection fees.
Findings
The Department issued a Statement of Deficiency (SOD #XCD215) citing violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A forfeiture of $600 was imposed for these violations, with a reduced payment option of $390 if not appealed. Additionally, a $200 inspection fee was assessed for a revisit to verify correction of prior violations.

Report Facts
Forfeiture amount: 600 Reduced forfeiture amount: 390 Revisit inspection fee: 200 Compliance timeframe: 45 Forfeiture payment due timeframe: 10 Appeal request timeframe: 10 Revisit fee payment due timeframe: 10

Employees mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Hillary HolmanAssisted Living Regional DirectorContact person for questions about the letter

Inspection Report

Complaint Investigation
Census: 41 Deficiencies: 1 Date: Sep 3, 2025

Visit Reason
Surveyor conducted a complaint investigation and verification visit at Riverview Village Senior Living on 09/03/2025 following a complaint.

Complaint Details
The complaint was unsubstantiated. A $200 revisit fee was assessed under Wis. Stat. Ch. 50.
Findings
One deficiency was identified related to inadequate health monitoring and failure to document communication with physicians for two residents. The complaint was unsubstantiated, and all previous deficiencies from the prior survey were substantially corrected.

Deficiencies (1)
Provider did not ensure 2 of 2 residents reviewed had their health monitored and communication with the resident's physician documented in the resident's record. Resident 6's heart rate was not documented over 65 days, and Resident 8's high blood sugar readings were not reported to the physician.
Report Facts
Revisit fee: 200 Census: 41 Days without heart rate documentation: 65 Occurrences of high blood sugar without physician notification: 4

Employees mentioned
NameTitleContext
Clinical Director OClinical DirectorInterviewed regarding health monitoring deficiencies and corrective actions.
Caregiver PInterviewed regarding Resident 8's blood sugar parameters.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Feb 19, 2025

Visit Reason
A complaint investigation, standard survey, and verification visit were conducted to determine if Riverview Village Senior Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.

Complaint Details
The visit was complaint-related, involving a complaint investigation, standard survey, and verification visit to assess compliance with applicable statutes and codes.
Findings
The Department issued a Statement of Deficiency (SOD #XCD214) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation, Order to Comply, Special Orders for corrective measures, and a forfeiture of $950.00. A $200 inspection fee was also assessed for a verification visit.

Deficiencies (1)
Health monitoring deficiency identified in Statement of Deficiency XCD214
Report Facts
Forfeiture amount: 950 Reduced forfeiture amount: 617.5 Inspection fee: 200 Compliance timeframe: 45 Payment timeframe: 10

Employees mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Hillary HolmanAssisted Living Regional DirectorContact person for questions about the letter

Inspection Report

Complaint Investigation
Census: 34 Deficiencies: 2 Date: Feb 19, 2025

Visit Reason
The surveyor conducted a complaint investigation, standard survey, and verification visit at Riverview Village Senior Living from 02/11/2025 to 02/19/2025, triggered by a complaint alleging concerns about a resident having daily falls.

Complaint Details
The complaint was substantiated. It involved concerns about a resident having daily falls and inadequate reassessment and monitoring of residents' health conditions.
Findings
Two deficiencies were identified, including a repeat violation. The provider failed to reassess Resident 5's needs after multiple falls and suicidal remarks, and failed to monitor and document communication with physicians regarding significant health changes for Residents 6 and 7. The complaint was substantiated and a $200 revisit fee was assessed.

Deficiencies (2)
The provider did not ensure the needs, abilities, and physical/mental condition were assessed for Resident 5 after sustaining 8 falls and making suicidal remarks.
The provider did not ensure health monitoring and documentation of communication with physicians for Residents 6 and 7 regarding high blood pressure and high blood sugar readings.
Report Facts
Revisit fee: 200 Number of deficiencies identified: 2 Number of falls: 8 Blood pressure reading: 153 Blood sugar readings: 559 Blood sugar readings: 494

Employees mentioned
NameTitleContext
Nurse MNurseAcknowledged lack of reassessment and documentation for Resident 5, 6, and 7; reported need for staff reeducation
Executive Director LExecutive DirectorInterviewed and findings shared during survey

Notice

Deficiencies: 0 Date: Aug 22, 2024

Visit Reason
The document serves as a statutory notice of violation and order to comply issued to Riverview Village Senior Living following an inspection conducted on August 22, 2024, to determine 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 at Riverview Village Senior Living, resulting in a Statement of Deficiency #XCD213 and imposed forfeiture totaling $330.00. A verification visit on August 22, 2024, assessed correction of prior violations and imposed a $200 inspection fee for the revisit.

Report Facts
Forfeiture amount: 330 Reduced forfeiture amount: 214.5 Forfeiture component: 150 Forfeiture component: 180 Revisit inspection fee: 200 Compliance timeframe: 45 Payment timeframe: 10

Employees mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Hillary HolmanAssisted Living Regional DirectorContact person for questions about the letter

Inspection Report

Complaint Investigation
Census: 40 Deficiencies: 2 Date: Aug 22, 2024

Visit Reason
Surveyors conducted a verification visit and two complaint investigations at Riverview Village Senior Living, including a review of a complaint related to an incident involving law enforcement on 07/06/2024 and medication administration concerns.

Complaint Details
One complaint related to an incident on 07/06/2024 involving law enforcement was substantiated. The provider failed to report the incident timely and did not document the incident in facility records initially. Another complaint was unsubstantiated.
Findings
Two deficiencies were identified, including a repeat violation for failure to report law enforcement involvement within three working days and a medication administration deficiency where Resident 5 missed six doses of prescribed atorvastatin between 06/17/2024 and 06/30/2024. One complaint was substantiated and one was unsubstantiated.

Deficiencies (2)
Failure to send a written report to the Department within 3 working days after law enforcement personnel were called to the facility due to an incident jeopardizing resident or employee safety.
Resident 5 did not receive prescribed medication (atorvastatin) in the correct dosage and intervals, missing six doses between 06/17/2024 and 06/30/2024.
Report Facts
Revisit fee: 200 Missed medication doses: 6

Employees mentioned
NameTitleContext
AExecutive DirectorInterviewed regarding the incident on 07/06/2024 and medication administration concerns.
KWellness CoordinatorInterviewed during exit conference and discussed provider's self-reports and medication concerns.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: May 2, 2024

Visit Reason
A complaint investigation and verification visit was conducted on May 2, 2024, to determine if Riverview Village Senior Living 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 codes. The Department found violations and issued enforcement actions including forfeiture and special orders.
Findings
The Department issued a Statement of Deficiency (SOD #XCD212) citing violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation, an Order to Comply, Special Orders requiring corrective actions within 45 days, and an imposed forfeiture of $800. A follow-up verification visit was conducted on May 2, 2024, to assess correction of prior violations, with a $200 inspection fee imposed for the revisit.

Deficiencies (1)
Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #XCD212
Report Facts
Forfeiture amount: 800 Reduced forfeiture amount: 520 Inspection fee: 200 Compliance timeframe: 45 Payment timeframe: 10

Employees mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Hillary HolmanAssisted Living Regional DirectorContact person for questions about the letter

Inspection Report

Complaint Investigation
Census: 42 Capacity: 48 Deficiencies: 2 Date: May 2, 2024

Visit Reason
Surveyor conducted 2 complaint investigations and a verification visit at Riverview Village Senior Living to investigate complaints and verify compliance with laws governing the facility.

Complaint Details
Two complaint investigations were conducted; one complaint was substantiated and one was unsubstantiated. The substantiated complaint involved failure to follow a resident's care plan leading to negative outcomes including amputation and fractures.
Findings
Two deficiencies were identified, including one cited for the third time related to failure to follow a resident's individual service plan, which led to the amputation of a resident's foot. One complaint was substantiated and one was unsubstantiated. The facility failed to comply with laws governing the CBRF, resulting in negative resident outcomes including fractures, weight loss, and unsupervised residents.

Deficiencies (2)
Failure to implement and follow Resident 4's individual service plan, resulting in a right foot amputation.
Failure to comply with laws governing the CBRF as evidenced by 13 deficiencies identified over multiple surveys.
Report Facts
Revisit fee: 200 Deficiencies identified: 13 Complaints substantiated: 5 Facility capacity: 48 Census: 42

Employees mentioned
NameTitleContext
Executive Director AExecutive DirectorInterviewed regarding failure to follow Resident 4's ISP and internal investigation
Wellness Director HWellness DirectorInterviewed regarding incident and retraining of staff involved in Resident 4's care
Nurse BNurseCompleted provider's investigation dated 03/11/2024-03/21/2024

Inspection Report

Complaint Investigation
Deficiencies: 4 Date: Aug 8, 2023

Visit Reason
A complaint and self-report investigations were conducted to determine if Riverview Village Senior Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.

Complaint Details
The visit was complaint-related, triggered by a complaint and self-report investigations to assess compliance with applicable statutes and administrative codes.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation and an imposed forfeiture totaling $1600. The licensee was ordered to comply with requirements including monitoring residents' health and providing staff training.

Deficiencies (4)
Violation of Wis. Admin. Code § 83.20(2)(a-d)
Violation of Wis. Admin. Code § 83.35(3)(c)
Violation of Wis. Admin. Code § 83.35(3)(d)
Violation of Wis. Admin. Code § 83.38(1)(g)
Report Facts
Forfeiture amount: 1600 Forfeiture amount: 200 Forfeiture amount: 700 Forfeiture amount: 300 Forfeiture amount: 400 Compliance timeframe: 45 Payment timeframe: 10

Employees mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Hillary HolmanAssisted Living Regional DirectorContact person for questions about the letter

Inspection Report

Complaint Investigation
Census: 37 Deficiencies: 4 Date: Aug 8, 2023

Visit Reason
The surveyor conducted 2 complaint investigations and a self-report review at Riverview Village Senior Living based on complaints received regarding resident care and compliance with training requirements.

Complaint Details
Two complaints were investigated and both were substantiated. One complaint involved Resident 1 being left unattended on the toilet leading to a fall and fractures. The other complaint involved Resident 2's care, including failure to update the service plan and failure to document significant weight loss.
Findings
Four deficiencies were identified, including a repeat violation. Both complaints were substantiated. Deficiencies included failure to ensure employee training compliance, failure to follow individual service plans resulting in a resident fall, failure to update individual service plans to reflect changes in resident needs, and failure to monitor and document significant resident weight loss.

Deficiencies (4)
Caregiver F did not complete Department Approved training in first aid and choking within 90 days after starting employment.
Provider did not follow the individual service plan for Resident 1, who was left unattended on the toilet prior to a fall resulting in fractures.
Resident 2's individual service plan was not updated to include the use of a sit to stand mechanical lift for all transfers.
Provider did not monitor and document substantial weight loss for Resident 2, who lost approximately 40 pounds from May to June 2023.
Report Facts
Deficiencies identified: 4 Resident census: 37 Weight loss: 40 Dates: 03/30/2023 Dates: 02/24/2023 Dates: 04/04/2023 Incident date: 06/14/2023 Incident date: 06/11/2023

Employees mentioned
NameTitleContext
Caregiver FCaregiverNamed in deficiency for not completing required first aid and choking training within 90 days.
Caregiver DCaregiverNamed in deficiency for leaving Resident 1 unattended on the toilet, contributing to a fall.
Nurse BNurseInterviewed and confirmed deficiencies related to Resident 1 and Resident 2's care and service plan updates.
Administrator AAdministratorInterviewed regarding Caregiver F's training compliance and acknowledged the issue.

Inspection Report

Census: 37 Capacity: 48 Deficiencies: 1 Date: May 11, 2023

Visit Reason
Surveyors conducted a standard survey, complaint investigation, and two verification visits at Riverview Village Senior Living.

Complaint Details
The complaint was unsubstantiated.
Findings
One deficiency was identified related to equipment cleanliness and repair. The complaint was unsubstantiated, and all previous violations were substantially corrected.

Deficiencies (1)
The provider did not ensure equipment was in good repair and clean, including worn, discolored, and greasy kitchen cabinets, missing drawer cover, cabinet doors that did not close, missing cabinet door for cleaning chemicals, stained walls, soiled serving area, and tarnished pots and pans.
Report Facts
Revisit fee: 200

Employees mentioned
NameTitleContext
Executive Director OExecutive DirectorInterviewed regarding kitchen condition.
Maintenance NMaintenanceInterviewed about kitchen repairs and replacement schedule.
Cook PCookInterviewed about kitchen cabinet condition and cleaning.

Notice

Deficiencies: 0 Date: May 11, 2023

Visit Reason
A standard survey, verification visit, and complaint investigation were conducted to determine if Riverview Village Senior Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.

Complaint Details
The visit included a complaint investigation; however, no substantiation status or specific complaint details are provided in the document.
Findings
The Department issued a Statement of Deficiency for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, requiring the licensee to comply with all requirements to protect resident health, safety, and welfare. An inspection fee of $200 was assessed for a verification visit to determine correction of prior violations.

Report Facts
Inspection fee: 200 Appeal filing deadline: 10 Compliance timeframe: 45 Posting duration: 90

Employees mentioned
NameTitleContext
Kathleen D. LyonsInterim Assisted Living DirectorSigned the notice letter.
Hillary HolmanAssisted Living Regional DirectorContact person for questions about the letter.

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