Inspection Reports for Silverado North Shore Memory Care Community
WI, 53217
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/year
Deficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
68% occupied
Based on a October 2025 inspection.
Census over time
Inspection Report
Enforcement
Deficiencies: 0
Oct 24, 2025
Visit Reason
A verification visit was conducted on October 24, 2025, to determine if Silverado North Shore was in substantial compliance with Wisconsin Statutes and Administrative Code requirements for community-based residential facilities. The visit was to assess compliance and resulted in issuance of a Statement of Deficiency and enforcement actions.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, leading to a Notice of Violation and an Order to Comply. The licensee was ordered to develop and implement corrective measures related to residents' rights to live in the least restrictive environment, including procedures for restrictive measures, staff training, and monitoring. A $200 inspection fee was imposed for a revisit to verify correction of prior violations.
Report Facts
Inspection fee: 200
Compliance timeframe: 45
Appeal timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter. |
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Re-Inspection
Census: 58
Capacity: 85
Deficiencies: 1
Oct 24, 2025
Visit Reason
The surveyor completed a verification visit to Silverado North Shore to assess correction of previous deficiencies and re-cite unresolved issues related to window opening restrictions.
Findings
Three of the previous four deficiencies were corrected, but one deficiency regarding restricted window openings in resident bedrooms was re-cited for the fifth time. The facility did not ensure all resident bedrooms had windows with an openable area meeting the department's 4% floor area requirement.
Deficiencies (1)
| Description |
|---|
| Resident bedrooms did not have at least one outside window with an openable area not less than 4% of the floor area; specifically, rooms 208 and 209 had window openings restricted to approximately 3.38 inches. |
Report Facts
Revisit fee: 200
Number of previous deficiencies corrected: 3
Number of previous deficiencies re-cited: 1
Facility total capacity: 85
Census: 58
Room 208 size: 355.39
Room 208 window size: 6.67
Room 208 window opening height: 3.38
Room 208 window opening width: 2.27
Room 209 size: 355.83
Room 209 window size: 5.55
Room 209 window opening height: 3.38
Room 209 window opening width: 3.08
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator F | Interviewed regarding window restrictions and measurement compliance. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Jan 31, 2025
Visit Reason
Surveyor completed 1 complaint investigation and 1 self-report investigation at Silverado North Shore.
Findings
No deficiencies were identified. The complaint and self-report were unsubstantiated.
Complaint Details
The complaint and self-report were unsubstantiated.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Aug 16, 2024
Visit Reason
Surveyor conducted a complaint investigation at Silverado North Shore.
Findings
No deficiencies were identified, and the complaint was unsubstantiated.
Complaint Details
Complaint was unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 21, 2024
Visit Reason
A survey/complaint/verification visit was conducted to determine if Silverado North Shore was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, including orders to comply with requirements and corrective measures related to residents' rights and restrictive measures. A forfeiture of $1000 was imposed, with a reduced option of $650 if not appealed.
Complaint Details
The visit was complaint-related, conducted to verify compliance with statutory and administrative requirements. The Department issued a Statement of Deficiency and imposed enforcement actions including a forfeiture and special orders.
Deficiencies (1)
| Description |
|---|
| Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 related to operation and administration of the community-based residential facility. |
Report Facts
Forfeiture amount: 1000
Reduced forfeiture amount: 650
Inspection fee: 200
Compliance timeframe: 45
Extension request timeframe: 10
Posting duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MaryBeth Hoffman | 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
Census: 62
Capacity: 85
Deficiencies: 4
Feb 21, 2024
Visit Reason
Surveyors completed a standard survey, verification visit, and a complaint investigation at Silverado North Shore. The visit included a review of fire drills, evacuation drills, combustible materials placement, and window safety compliance.
Findings
Four deficiencies were identified, three of which were repeat violations. Deficiencies included combustible materials stored too close to water heaters, failure to conduct required fire evacuation and other emergency drills in 2022, and windows in resident rooms and common areas restricted from opening to the required size. One complaint was unsubstantiated.
Complaint Details
One complaint was investigated and found to be unsubstantiated.
Deficiencies (4)
| Description |
|---|
| Combustible materials were placed within 3 feet of water heaters, including 2 boxes within 6 inches and a mattress within 12 inches. |
| Fire evacuation drills were not conducted at least quarterly with employees and residents in 2022; only one drill was documented and it did not simulate sleeping hours. |
| Other evacuation drills (tornado, flooding, or other emergencies) were not conducted at least semi-annually in 2022; two drills were missed. |
| Windows in 28 of 30 second floor bedrooms and 1 of 3 common areas were restricted to opening approximately 3 inches, less than the required 4% of floor area; a waiver request to restrict window openings was denied. |
Report Facts
Revisit fee: 200
Census: 62
Total capacity: 85
Fire evacuation drills conducted: 1
Fire evacuation drill evacuation time: 40
Second floor bedrooms with restricted windows: 28
Second floor bedrooms total: 30
Common areas with restricted windows: 1
Required fire evacuation drills per year: 4
Required other evacuation drills per year: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E | Director of Plant Operations | Interviewed regarding combustible materials placement, fire drills, and window restrictions. |
| D | Director of Health Services | Interviewed about window restrictions and facility knowledge. |
| C | Administrator | Interviewed about window restrictions and plans to address screws in windows. |
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