Inspection Reports for Rolling Meadows of Strum
208 ELM STREET, STRUM, WI, 54770
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
42% occupied
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: 0
Date: Sep 3, 2025
Visit Reason
A complaint investigation, self-report, investigation, and verification visit were conducted to determine if Rolling Meadows of Strum 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, self-report, investigation, and verification visit to assess compliance with applicable statutes and codes.
Findings
The Department issued a Statement of Deficiency (SOD #ZY4717) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements, not admit new residents until compliance is verified, and to consult with a registered nurse to correct deficiencies. A forfeiture of $7,700 was imposed for the violations, with a reduced payment option of $5,005. An inspection fee of $200 was also assessed for a verification visit.
Report Facts
Forfeiture amount: 7700
Reduced forfeiture amount: 5005
Forfeiture by tag: 1000
Forfeiture by tag: 400
Forfeiture by tag: 1800
Forfeiture by tag: 3400
Forfeiture by tag: 1100
Inspection fee: 200
Compliance timeframe: 45
Extension request timeframe: 10
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 |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 50
Deficiencies: 13
Date: Sep 3, 2025
Visit Reason
Surveyors conducted complaint investigations, verification visits, and self-report reviews triggered by multiple complaints alleging concerns including sexual assault and resident falls.
Complaint Details
Eight complaints were substantiated, including allegations of sexual assault, inadequate supervision, and failure to notify legal representatives. Multiple self-reports were reviewed. The provider was assessed a $200 revisit fee under statutory provisions.
Findings
Thirteen deficiencies were identified, including failures to report abuse to law enforcement, investigate injuries of unknown source, notify legal representatives of incidents and medication changes, provide adequate supervision, update and implement individualized service plans, monitor resident health, and maintain complete resident records. Several deficiencies were repeat violations.
Deficiencies (13)
Failure to report allegations of sexual assault to law enforcement.
Failure to investigate injuries of unknown source for a resident with multiple unexplained injuries.
Failure to immediately notify a resident's legal representative of medication changes.
Failure to immediately notify a resident's legal representative of abuse allegations.
Failure to ensure the facility complies with all laws governing the CBRF.
Failure to assess residents for changes in needs, abilities, or condition after exhibiting sexual behaviors.
Failure to develop comprehensive individualized service plans identifying services, frequency, approaches, and responsible staff for wound care.
Failure to involve resident or legal representative in individual service plan development and obtain signature acknowledging involvement.
Failure to implement individualized service plans as written, resulting in resident elopements and inadequate supervision.
Failure to update individual service plans annually or when there are changes in resident needs, including supervision and sexual behavior interventions.
Failure to provide supervision appropriate to residents' needs, resulting in multiple elopements, falls, and sexual behavior incidents.
Failure to monitor resident health adequately, including documentation and monitoring of skin breakdown and wound care.
Failure to maintain complete resident records, including missing written physician orders for medication changes prior to a medical procedure.
Report Facts
Complaints substantiated: 8
Deficiencies identified: 13
Repeat violations: 4
Residents present: 21
Licensed capacity: 50
Resident falls documented: 5
Resident falls documented: 7
Resident elopements reported: 5
Resident falls reported: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director E | Director | Interviewed regarding investigations, supervision, wound care, and notification failures. |
| Assistant Director K | Assistant Director | Interviewed regarding supervision, investigations, and wound care. |
| Administrative Assistant B | Administrative Assistant | Interviewed regarding notifications and documentation. |
| Caregiver S | Caregiver | Mentioned in relation to abuse investigation and failure to notify legal representative. |
| Caregiver U | Caregiver | Interviewed during abuse investigation with inconsistent statements. |
| Caregiver C | Caregiver | Interviewed regarding resident elopements. |
| Caregiver D | Caregiver | Interviewed regarding resident elopements. |
| Caregiver G | Caregiver | Interviewed regarding resident elopements. |
| Caregiver H | Caregiver | Interviewed regarding resident elopements. |
| Cook R | Cook | Mentioned in relation to resident elopement. |
| Police Officer O | Police Officer | Interviewed regarding concerns about resident supervision. |
| Home Health Nurse Z | Home Health Nurse | Interviewed regarding wound care and toileting schedule compliance. |
| Primary Care Nurse L | Primary Care Nurse | Interviewed regarding medication instructions for Resident 7. |
| Licensee A | Licensee | Interviewed regarding overall facility operations and compliance. |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 0
Date: May 2, 2025
Visit Reason
A complaint investigation was conducted at Rolling Meadows of Strum starting on 2025-05-02, with data collection continuing through 2025-05-05.
Complaint Details
Three complaints were investigated and all were unsubstantiated.
Findings
Three complaints were investigated and all were found to be unsubstantiated. No deficiencies were identified during the investigation.
Report Facts
Complaints investigated: 3
Notice
Deficiencies: 0
Date: Jan 8, 2025
Visit Reason
A verification visit and complaint investigation was conducted on January 8, 2025, to determine if Rolling Meadows of Strum 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 determine compliance. Specific substantiation status is not stated.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency (SOD #ZY4716), a forfeiture of $400, and an imposed $200 inspection fee for a revisit to verify correction of violations.
Report Facts
Forfeiture amount: 400
Reduced forfeiture amount: 260
Revisit inspection fee: 200
Compliance timeframe: 45
Payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| William R. Gardner | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 18
Capacity: 19
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
Surveyors conducted 3 complaint investigations and 2 verification visits at Rolling Meadows of Strum on 01/08/2025. The complaints were unsubstantiated and a $200 revisit fee was assessed.
Complaint Details
The complaints investigated were unsubstantiated.
Findings
One repeat deficiency was identified related to failure to conduct quarterly fire evacuation drills with both employees and residents. Documentation showed incomplete participation and training without actual drills involving all residents and staff.
Deficiencies (1)
Provider did not conduct fire evacuation drills with both employees and residents quarterly as required.
Report Facts
Revisit fee: 200
Number of complaint investigations: 3
Number of verification visits: 2
Residents evacuated in fire drill: 4
Residents refusing evacuation: 3
Residents with no noted evacuation status: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director A | Interviewed about fire drill protocol and acknowledged importance of resident and staff participation and documentation |
Inspection Report
Complaint Investigation
Census: 17
Capacity: 19
Deficiencies: 7
Date: Jul 9, 2024
Visit Reason
Surveyor conducted a 6-complaint investigation at Rolling Meadows of Strum due to multiple complaints alleging resident care needs were not met and issues with facility operations and oversight.
Complaint Details
The investigation was triggered by six complaints alleging inadequate resident care, lack of administrator oversight, and failure to respond appropriately to changes in residents' conditions. Four of the six complaints were substantiated.
Findings
Four of six complaints were substantiated. Seven deficiencies were identified, five of which were repeat violations. Key issues included failure to ensure compliance with laws, inadequate supervision by the administrator, failure to provide prompt and adequate treatment, medication errors, lack of proper health monitoring, and incomplete individualized service plans.
Deficiencies (7)
Licensee did not ensure the facility complied with all laws governing the CBRF.
Administrator did not supervise daily operations, including ensuring proper care, health and safety, and residents' rights.
Provider did not ensure Resident 1 received prompt and adequate treatment when experiencing a change in condition leading to death; delay in calling 911.
Provider did not ensure Resident 2's advance directive/DNR order or bracelet were available to emergency personnel.
Resident 2 did not receive all prescribed medications as ordered, including insulin, roflumilast, and levothyroxin.
Provider did not ensure Resident 1 had a comprehensive individualized service plan identifying needs and desired outcomes related to wound care, support services, and advanced directives.
Provider did not ensure Resident 1's health was monitored adequately; toe wounds were not consistently assessed, leading to cellulitis and amputation.
Report Facts
Complaints investigated: 6
Complaints substantiated: 4
Deficiencies identified: 7
Repeat deficiencies: 5
Licensed capacity: 19
Resident census: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator B | Administrator | Named in findings related to failure to supervise daily operations and delayed response to Resident 1's change in condition. |
| Licensee A | Licensee | Named in findings related to oversight failures and delayed emergency response. |
| Registered Nurse J | Registered Nurse | Named in findings related to wound care oversight and staff education. |
| Caregiver D | Named in findings related to delayed emergency response and misunderstanding of Resident 1's code status. | |
| Assistant Administrator C | Assistant Administrator | Named in findings related to investigation and staff communication. |
| Caregiver F | Named in findings related to performing CPR and emergency response. | |
| Caregiver N | Named in findings related to communication failures about Resident 1's condition. | |
| Caregiver M | Named in findings related to medication administration and staff training. | |
| Caregiver I | Named in findings related to medication administration and wound care training. | |
| Caregiver G | Named in findings related to wound observation and reporting. | |
| Caregiver H | Named in findings related to resident transfer to emergency room. | |
| Caregiver P | Named in findings related to communication with emergency medical technicians about Resident 2's DNR status. | |
| Caregiver Q | Named in findings related to resident hospice status and communication. | |
| Home Health Nurse L | Home Health Nurse | Named in findings related to wound care oversight and communication with facility. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 9, 2024
Visit Reason
A complaint investigation was conducted on 2024-07-09 to determine if Rolling Meadows of Strum was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
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 #UWFF11 and enforcement actions.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency (SOD #UWFF11) and imposed orders including corrective actions, consultant requirements, staff training, and a forfeiture.
Report Facts
Forfeiture amount: 4480
Reduced forfeiture amount: 2912
Forfeiture breakdown: 1000
Forfeiture breakdown: 400
Forfeiture breakdown: 1680
Forfeiture breakdown: 600
Forfeiture breakdown: 300
Forfeiture breakdown: 500
Compliance timeframe: 45
Payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William R. Gardner | 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
Deficiencies: 0
Date: Feb 23, 2024
Visit Reason
A standard survey, complaint investigation, and verification visit was conducted to determine if Rolling Meadows of Strum was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit included a complaint investigation as part of the standard survey and verification process. The report does not explicitly state the substantiation status of the complaint.
Findings
The Department issued a Statement of Deficiency (SOD #ZY4715) identifying multiple violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply immediately and develop corrective measures within 45 days. A total forfeiture of $5,500 was imposed for the violations, with a reduced forfeiture option of $3,575 if not appealed. An inspection fee of $200 was also assessed for a verification visit.
Report Facts
Forfeiture amount: 5500
Reduced forfeiture amount: 3575
Forfeiture breakdown: 300
Forfeiture breakdown: 150
Forfeiture breakdown: 1000
Forfeiture breakdown: 1400
Forfeiture breakdown: 1050
Forfeiture breakdown: 1200
Forfeiture breakdown: 400
Inspection fee: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William R. Gardner | Assisted Living Regional Director | Contact person for questions about the letter. |
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter. |
Inspection Report
Complaint Investigation
Census: 19
Capacity: 19
Deficiencies: 10
Date: Feb 1, 2024
Visit Reason
Surveyors conducted a verification visit, complaint investigation, and licensure survey at Rolling Meadows of Strum due to a complaint which was substantiated.
Complaint Details
The complaint was substantiated. It involved allegations of caregiver misconduct including misappropriation of Resident 3's funds and failure to report incidents and injuries timely.
Findings
Ten deficiencies were identified, including repeat violations. Key issues included failure to report caregiver misconduct, failure to report serious injury incidents timely, inadequate staff training, incomplete individualized service plans, lack of resident satisfaction evaluations, inadequate transportation arrangements, unsecured oxygen storage, and incomplete fire drill documentation.
Deficiencies (10)
Failure to report caregiver misconduct to the Department after concluding allegations of misappropriation of Resident 3's funds.
Failure to send a written report within 3 working days after Resident 12's fall resulting in emergency room treatment for fractured wrist and head injury.
Failure to ensure the facility complies with all laws governing the community based residential facility (CBRF), including corrective measures and staff training.
Failure to ensure department-approved training courses were completed by staff, including fire safety, first aid and choking, and standard precautions.
Failure to ensure all employee training requirements were met within 90 days of employment, including resident rights, challenging behaviors, and client group specific training.
Failure to develop comprehensive individualized service plans for Residents 4, 9, and 12 that accurately identify needs and desired outcomes.
Failure to provide resident satisfaction evaluations annually to residents and their legal representatives.
Failure to provide or arrange adequate transportation for Resident 12, resulting in an unwitnessed fall in the facility parking lot after returning from the emergency room via taxi.
Failure to ensure oxygen cylinders were secured when stored upright in Resident 11's room.
Failure to conduct quarterly fire drills in 2023 with required documentation including evacuation times and assistance needed.
Report Facts
Deficiencies identified: 10
Repeat deficiencies: 4
Census: 19
Total capacity: 19
Fine amount: 200
Falls: 7
Fire drills documented: 4
Fire drills missing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver D | Named in misappropriation of Resident 3's funds and lack of required training. | |
| Licensee B | Interviewed regarding reporting, training, and compliance issues. | |
| Licensee C | Interviewed regarding reporting, training, and compliance issues. | |
| Director A | Signed investigation report related to caregiver misconduct. | |
| Assistant Director J | Interviewed regarding Resident 12's falls and reporting. | |
| Caregiver F | Named in lack of required training. | |
| Caregiver H | Named in lack of required training. | |
| Caregiver K | Interviewed about choking interventions for Resident 12. | |
| POA L | Power of attorney for Resident 9, interviewed about care and falls. | |
| POA N | Power of attorney for Resident 12, interviewed about fall incident. | |
| Case Manager O | Interviewed about Resident 12's supervision and transportation needs. | |
| Caregiver E | Interviewed about fire drills. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
A complaint investigation and verification visit were conducted to determine if Rolling Meadows of Strum 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 and verification visit to assess compliance with statutory and administrative requirements. The Department issued a Statement of Deficiency (SOD #ZY4714) based on findings from the investigation.
Findings
The Department issued a Statement of Deficiency (SOD #ZY4714) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements immediately, develop corrective measures including written procedures and staff training, and submit investigation reports related to caregiver misconduct. A total forfeiture of $1,700 was imposed for the violations, with a reduced forfeiture option of $1,235 if not appealed. An inspection fee of $200 was also assessed for a verification visit.
Report Facts
Forfeiture amount: 1700
Reduced forfeiture amount: 1235
Forfeiture amount by tag N158: 500
Forfeiture amount by tag N205: 400
Forfeiture amount by tag N352: 200
Forfeiture amount by tag N358: 600
Forfeiture amount by tag N425: 200
Inspection fee: 200
Compliance timeframe: 45
Investigation report submission timeframe: 14
Notification timeframe: 7
Appeal timeframe: 10
Revisit fee: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| William R. Gardner | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 19
Capacity: 19
Deficiencies: 7
Date: Jul 13, 2023
Visit Reason
Surveyors conducted a verification visit and complaint investigation at Rolling Meadows of Strum due to a complaint which was substantiated.
Complaint Details
The complaint was substantiated. The investigation included issues related to abuse neglect investigation, medication administration, facility compliance with laws, and resident safety.
Findings
Seven deficiencies were identified, including repeat deficiencies. Key issues included failure to complete a misappropriation investigation, noncompliance with laws governing the facility, malfunctioning wireless call system, medication administration without consent, unsafe physical environment, incomplete individualized service plans, and inadequate personal care.
Deficiencies (7)
Failure to complete a misappropriation investigation when Resident 2 reported money missing.
Licensee did not ensure the facility complied with all laws governing the CBRF, including failure to complete special orders and correct deficiencies.
Provider's pendant wireless call system was not functioning properly for multiple months, putting residents at risk.
Resident 4 was administered medication (naltrexone) without consent from the resident or power of attorney.
Physical environment was unsafe and not well-maintained, including a Hoyer lift blocking an emergency exit, frayed carpet posing fall risk, missing smoke detector, and unpainted wall patches.
Resident 4's individualized service plan did not address alcohol consumption or use of medication to wean off alcohol.
Resident 1 did not receive adequate personal care assistance, going multiple days without having clothes changed.
Report Facts
Deficiencies identified: 7
Repeat deficiencies: 4
Licensed capacity: 19
Census: 19
Substantiated complaints since licensure: 11
Total deficiencies since licensure: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director A | Director | Interviewed regarding misappropriation investigation, wireless call system issues, medication management, and personal care concerns. |
| Caregiver D | Caregiver | Interviewed about wireless call system and medication concerns. |
| Caregiver J | Caregiver | Interviewed about wireless call system issues. |
| Caregiver M | Caregiver | Interviewed about wireless call system and pendant issues. |
| Caregiver L | Caregiver | Interviewed about Resident 5's call pendant. |
| POA E | Power of Attorney | Interviewed regarding medication consent for Resident 4. |
| Family Member F | Interviewed regarding medication consent for Resident 4. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 9, 2023
Visit Reason
Complaint investigations and verification visits were conducted to determine if Rolling Meadows of Strum was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, involving complaint investigations and verification visits to assess compliance with statutory and administrative requirements. The Department issued a Statement of Deficiency and imposed enforcement actions including forfeiture and orders to comply.
Findings
The Department issued a Statement of Deficiency (SOD #ZY4713) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply immediately with requirements, develop corrective measures including written procedures and staff training addressing caregiver misconduct, medication management, and water temperature safety. A total forfeiture of $2,100 was imposed for the violations, with a reduced forfeiture option of $1,365 if not appealed. A $200 inspection fee was also assessed for a verification visit conducted on 02/09/2023.
Deficiencies (1)
Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in Statement of Deficiency (SOD) #ZY4713
Report Facts
Forfeiture amount: 2100
Reduced forfeiture amount: 1365
Forfeiture breakdown: 200
Forfeiture breakdown: 200
Forfeiture breakdown: 500
Forfeiture breakdown: 350
Forfeiture breakdown: 400
Forfeiture breakdown: 450
Inspection fee: 200
Compliance timeframe: 45
Investigation report submission timeframe: 14
Forfeiture payment timeframe: 10
Revisit fee payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William R. Gardner | Assisted Living Regional Director | Contact person for questions about the letter |
| Kathleen D. Lyons | Interim Assisted Living Director | Signed the Notice and Order letter |
Inspection Report
Complaint Investigation
Census: 18
Capacity: 19
Deficiencies: 7
Date: Feb 9, 2023
Visit Reason
Surveyors conducted three complaint investigations and two verification visits at Rolling Meadows of Strum triggered by complaints and verification of previous deficiencies.
Complaint Details
One of three complaints was substantiated. The complaints involved allegations of abuse, neglect, misappropriation of property, medication errors, and failure to provide adequate treatment.
Findings
Seven deficiencies were identified, including failure to investigate resident property misappropriation, failure to notify resident's physician of significant condition changes, medication administration errors involving warfarin, delayed treatment for a resident with vomiting, unsafe water temperatures, and incomplete out-of-state background checks for employees.
Deficiencies (7)
Failure to complete investigation of resident property misappropriation when Resident 2 reported missing money.
Failure to immediately notify Resident 2's physician of incident, injury, or significant change in condition.
Failure to ensure Resident 1 received all prescribed doses of warfarin, including missed and wrong doses.
Failure to ensure Resident 2 received prompt and adequate treatment; delay in sending Resident 2 for evaluation after vomiting.
Hot water temperature at resident-accessible sinks exceeded safe limits (measured 124.5°F to 128.2°F).
Failure to complete out-of-state criminal background checks for 3 employees who resided outside Wisconsin within 3 years prior to hire.
Failure to ensure facility operation complied with all laws governing CBRF, including multiple repeat deficiencies from prior surveys.
Report Facts
Deficiencies identified: 7
Repeat deficiencies: 3
Revisit fee: 200
Residents present: 18
Licensed capacity: 19
Water temperature: 125.6
Water temperature: 128.2
Water temperature: 124.5
Warfarin missed doses: 1
Warfarin wrong doses: 6
Warfarin wrong dose or duplicate signature: 3
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