Inspection Reports for Stoughton Meadows Assisted Living
2321 JACKSON ST, STOUGHTON, WI, 53589
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
146% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
41 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Date: Oct 14, 2025
Visit Reason
A verification visit was conducted on 10/14/2025 to determine if Stoughton Meadows Assisted Living was in substantial 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, resulting in a Statement of Deficiency #RN3014, imposition of a forfeiture of $2,100, and special orders including consultation requirements and corrective actions related to medication management.
Report Facts
Forfeiture amount: 2100
Reduced forfeiture amount: 1365
Inspection fee: 200
Compliance timeframe: 45
Notification timeframe: 7
Payment timeframe: 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
Follow-Up
Census: 41
Deficiencies: 1
Date: Oct 10, 2025
Visit Reason
Surveyor conducted a verification visit at Stoughton Meadows Assisted Living to follow up on a previously identified deficiency related to medication administration.
Findings
One deficiency was identified, which was a repeat violation concerning the failure to administer medications as prescribed for 3 out of 5 residents reviewed. The deficiency is being cited for the seventh time.
Deficiencies (1)
Provider did not administer medications in the intervals prescribed by a practitioner for 3 out of 5 residents reviewed.
Report Facts
Revisit fee: 200
Residents reviewed: 5
Residents with medication not administered as prescribed: 3
Deficiency citation count: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Clinical Services | Interviewed by surveyor regarding medication administration and pharmacy issues | |
| Med Passer S | Observed medication administration and provided clarification on medication dispensing | |
| Mark R | Market Leader | Reviewed observations and documentation of medication administration and stated staff would continue re-education |
| Director Q | Interviewed by surveyor regarding medication administration | |
| Wellness Director O | Provided pharmacy delivery reports and documentation related to medication administration |
Notice
Deficiencies: 0
Date: Jun 9, 2025
Visit Reason
A verification visit was conducted on 06/09/2025 to determine if Stoughton Meadows Assisted Living was in substantial 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, resulting in a Statement of Deficiency (SOD) #RN3013 and imposed a total forfeiture of $1,700.00. A $200 inspection fee for a revisit to verify correction of prior violations (SOD #RN3012) was also assessed.
Report Facts
Forfeiture amount: 1700
Forfeiture amount: 1000
Forfeiture amount: 300
Forfeiture amount: 400
Reduced forfeiture amount: 1105
Revisit 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 |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Follow-Up
Census: 39
Deficiencies: 4
Date: Jun 9, 2025
Visit Reason
Surveyor conducted a verification visit at Stoughton Meadows Assisted Living to assess correction of previously identified deficiencies.
Findings
Four deficiencies were identified, three of which were repeat violations related to medication administration and individual service plan implementation. Staffing concerns and medication management issues were also noted.
Deficiencies (4)
Provider did not administer medications in the intervals prescribed by a practitioner for 5 out of 8 residents reviewed.
Provider did not implement 1 of 1 resident individual service plan (ISP) related to two-person transfers.
Provider did not have a physician order in writing for 1 of 1 resident to self-administer medications.
Provider did not ensure 2 of 2 residents reviewed received appropriate medication administration.
Report Facts
Deficiencies identified: 4
Repeat violations: 3
Revisit fee: 200
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DCS P | Director of Clinical Services | Observed medication administration deficiencies and interviewed by surveyor |
| Wellness Director O | Wellness Director | Observed medication administration deficiencies and interviewed by surveyor |
| Director N | Director of Nursing or Director of Clinical Services | Interviewed regarding staffing and medication administration |
| Director Q | Director | Interviewed regarding staffing and medication administration |
| Market Leader R | Market Leader | Discussed staffing concerns and re-education plans |
Inspection Report
Routine
Deficiencies: 1
Date: Nov 15, 2024
Visit Reason
A standard survey and verification visit was conducted on 11/15/2024 to determine if Stoughton Meadows Assisted Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #RN3012) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements related to medication management and administration, including staff training and written procedures. A total forfeiture of $1,740 was imposed for specific violations.
Deficiencies (1)
Violations related to medication management and administration, including documentation, administration, error prevention, and monitoring.
Report Facts
Forfeiture amount: 1740
Forfeiture amount: 500
Forfeiture amount: 740
Forfeiture amount: 300
Forfeiture amount: 200
Reduced forfeiture amount: 1131
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. |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Renewal
Census: 37
Capacity: 45
Deficiencies: 8
Date: Nov 15, 2024
Visit Reason
On 10/29/2024, with information gathered through 11/15/2024, a standard licensure survey and verification visits were conducted at Stoughton Meadows Assisted Living to assess compliance with licensing requirements and regulations.
Findings
Eight deficiencies were identified, including four repeat violations related to medication administration, service plan updates, health monitoring, and disposition of medications. The provider did not ensure compliance with all laws governing the community-based residential facility (CBRF). A $200 revisit fee is being assessed.
Deficiencies (8)
Licensee did not ensure facility complied with laws governing the CBRF.
Rights of residents to receive medication not ensured; cited for a fourth time.
Service plans not updated annually or on changes; repeat deficiency.
Disposition of medications not properly managed; repeat deficiency.
PRN psychotropic medication administration deficiencies.
Personal care services not adequately provided; repeat deficiency.
Health monitoring deficiencies; repeat deficiency.
Medication administration deficiencies including expired medications and improper documentation; repeat deficiency.
Report Facts
Deficiencies identified: 8
Repeat deficiencies: 4
Revisit fee: 200
Census: 37
Total capacity: 45
Complaint investigations: 4
Complaint substantiated: 4
Deficiencies identified in complaint investigations: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cluster Nurse K | Interviewed and provided statements regarding medication administration and deficiencies. | |
| Clinical Market Leader B | Interviewed regarding resident care and medication administration. | |
| Executive Director M | Executive Director | Interviewed and stated improvements have been made since the last survey process. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
Four complaint investigations were concluded for Stoughton Meadows 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, involving four complaint investigations concluded on 07/01/2024. The Department found violations and issued enforcement actions including a Statement of Deficiency and forfeiture.
Findings
The Department issued a Statement of Deficiency (SOD #RN3011) for violations of Wisconsin statutes and administrative codes, resulting in a Notice of Violation, Order to Comply, Special Orders including a required consultant, and a Notice of Imposed Forfeiture totaling $4,040.00.
Report Facts
Forfeiture amount: 4040
Reduced forfeiture amount: 2626
Forfeiture by tag N158: 800
Forfeiture by tag N348: 800
Forfeiture by tag N352: 1320
Forfeiture by tag N431: 1120
Compliance timeframe: 45
Investigation report submission timeframe: 14
Extension request timeframe: 10
Forfeiture payment timeframe: 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
Complaint Investigation
Census: 36
Capacity: 45
Deficiencies: 8
Date: Jul 1, 2024
Visit Reason
On 06/04/2024, surveyor conducted 4 complaint investigations at Stoughton Meadows Assisted Living following allegations of medication misappropriation and other concerns.
Complaint Details
Four of four complaints were substantiated, including medication misappropriation, inaccurate narcotic counts, dropped residents during transfer, and pest control issues.
Findings
Eight deficiencies were identified, including medication misappropriation, failure to ensure proper supervision and training, and infection control issues. Six of seven complaints were substantiated, with issues such as missing medications, improper medication administration, and pest control problems.
Deficiencies (8)
Caregiver failed to investigate and report abuse and neglect related to medication misappropriation.
Administrator did not supervise daily operation to ensure proper care, safety, and residents' rights.
Task specific training was inadequate for staff performing job duties including resident assessment and personal care.
Rights of residents to be free from mistreatment were not ensured; multiple residents experienced medication misappropriation.
Medication administration deficiencies including failure to administer medications as prescribed and failure to monitor health conditions such as blood glucose.
Infection control program was not followed according to current standards, including improper mask use and lack of sanitizer.
Pest control procedures were not implemented effectively; mouse droppings and pest control traps observed.
Disposition of medications was not properly documented or witnessed; outdated medications were not separated and disposed of correctly.
Report Facts
Deficiencies identified: 8
Complaints investigated: 4
Complaints substantiated: 4
Residents present: 36
Licensed capacity: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manager of Operations C | Manager of Operations | Interviewed regarding medication misappropriation and staff training issues |
| Wellness Coordinator D | Wellness Coordinator | Interviewed regarding medication destruction and medication record reviews |
| Executive Director A | Executive Director | Interviewed regarding medication misappropriation, narcotic counts, and pest control concerns |
| Clinical Market Leader B | Clinical Market Leader | Interviewed regarding medication concerns and staff education |
| Med Passer E | Medication Passer | Mentioned in relation to medication administration and training |
| Med Passer F | Medication Passer | Mentioned in relation to medication administration and training |
| Med Passer G | Medication Passer | Mentioned in relation to medication administration and training |
| Med Passer H | Medication Passer | Mentioned in relation to medication administration and training |
| Caregiver E | Caregiver | Mentioned in relation to medication documentation and training |
| Caregiver F | Caregiver | Mentioned in relation to medication documentation and training |
| Caregiver I | Caregiver | Mentioned in relation to training on Hoyer lift use |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 26, 2024
Visit Reason
A verification visit, three complaint investigations, and a self-report review were conducted to determine if Stoughton Meadows Assisted Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit included three complaint investigations and a self-report review to assess compliance with applicable statutes and administrative codes.
Findings
The Department issued Statement of Deficiency (SOD) #BTKI12 for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. Enforcement actions include an order to comply with requirements, special orders for corrective measures, and a forfeiture totaling $1,800.00.
Report Facts
Forfeiture amount: 1800
Reduced forfeiture amount: 1170
Forfeiture by tag N310: 200
Forfeiture by tag N353: 400
Forfeiture by tag N388: 800
Forfeiture by tag N389: 400
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 |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 10
Date: Apr 26, 2024
Visit Reason
Surveyors conducted a verification visit including 3 complaint investigations and a self-report review at Stoughton Meadows Assisted Living, triggered by complaints alleging overcharging and inadequate care.
Complaint Details
Two of three complaints were substantiated. Complaints included allegations of overcharging room fees, staff not awake during scheduled hours resulting in residents sitting in incontinence, and misuse of morphine with hospice residents.
Findings
Ten deficiencies were identified, including two repeat violations. Two of the three complaints were substantiated. Deficiencies involved admission agreements, resident rights, adequate treatment, service plan development and implementation, medication administration documentation, and environmental safety.
Deficiencies (10)
Admission agreements did not include all additional services offered and charges, including non-emergency EMS personnel charges.
Provider did not ensure 1 resident received adequate treatment after displaying non-baseline signs and symptoms; resident was found deceased.
Provider did not ensure 2 residents had admission agreements outlining all required terms including facility being no-lift and associated fees.
Provider did not ensure 1 resident's Individual Service Plan (ISP) was signed by resident or legal representative acknowledging involvement and agreement.
Provider did not ensure 1 resident's ISP was followed as written, including use of call light for fall risk; response time was delayed.
Provider did not maintain a proof-of-use record for schedule II medication for 1 resident; narcotic count sheets did not align with actual narcotics available.
Provider did not ensure a safe, clean, comfortable, and homelike environment; resident's room had food debris, soiled clothes, missing bathroom door, broken door stop, and brown matter on garbage can.
Provider did not ensure 1 resident had a comfortable mattress; resident's bed was sunken with a two-mattress system and a six-inch gap between mattresses.
Provider did not ensure 1 resident's medication administration was properly documented; discrepancies in medication administration record and destruction record for Lorazepam.
Provider did not ensure 1 resident's Individual Service Plan was updated when there was a change in resident needs and abilities; repeat deficiency.
Report Facts
Deficiencies identified: 10
Complaints investigated: 3
Complaints substantiated: 2
Revisit fee: 200
Census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| A. ED A | Executive Director | Interviewed regarding resident room charges, admission agreements, and service plan documentation. |
| H. RN H | Registered Nurse | Interviewed regarding room fee schedules, internal death investigation, call light response times, and medication administration concerns. |
| K. Caregiver K | Caregiver | Interviewed regarding awareness of resident death and frequent checks. |
| J. Cook J | Cook | Reported observations of resident condition prior to death. |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Date: Jan 24, 2024
Visit Reason
The Bureau of Assisted Living, Southern Regional Office conducted a complaint investigation at Stoughton Meadows Assisted Living, a CBRF located in Stoughton, WI.
Complaint Details
Complaint was unsubstantiated
Findings
As a result of the investigation, zero violations of Chapter DHS 83 were issued. The complaint was unsubstantiated.
Report Facts
Violations issued: 0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 15, 2023
Visit Reason
Two complaint investigations were concluded to determine if Stoughton Meadows Assisted Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
Two complaint investigations were concluded on 11/15/2023 to assess compliance; violations were found and substantiated as indicated by the issuance of SOD #BTKI11.
Findings
The Department issued a Statement of Deficiency (SOD #BTKI11) for violations of Wisconsin statutes and administrative codes, resulting in a Notice of Violation, an Order to Comply, and an imposed forfeiture totaling $600.
Report Facts
Forfeiture amount: 600
Forfeiture amount: 200
Forfeiture amount: 400
Forfeiture payment deadline days: 10
Compliance deadline days: 45
Reduced forfeiture percentage: 35
Reduced forfeiture amount: 390
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
Complaint Investigation
Census: 36
Deficiencies: 0
Date: Sep 21, 2023
Visit Reason
The Bureau of Assisted Living, Southern Regional Office conducted a complaint investigation and self-report review at Stoughton Meadows, a CBRF located in Stoughton, WI.
Complaint Details
Complaint was unsubstantiated.
Findings
As a result of the investigation, 0 violations of Chapter DHS 83 were issued. The complaint was unsubstantiated.
Report Facts
Violations issued: 0
Inspection Report
Routine
Deficiencies: 0
Date: Jan 27, 2023
Visit Reason
A standard survey and verification visit was conducted on 01/27/2023 at Stoughton Meadows Assisted Living to determine if the facility was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD) #UOVI13 for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements to protect resident health, safety, and welfare. A subsequent verification visit was conducted to assess correction of prior deficiencies.
Report Facts
Inspection fee: 200
Days to achieve compliance: 45
Appeal filing period: 10
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Perron | Assisted Living Director | Signed the notice and order letter |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Enforcement
Census: 37
Deficiencies: 2
Date: Jan 27, 2023
Visit Reason
On 01/26/2023, The Bureau of Assisted Living, Southern Regional Office conducted an Enforcement Verification Visit and Standard Survey at Stoughton Meadows, a CBRF located in Stoughton, WI.
Findings
As a result of this survey, 2 violations of Chapter DHS 83 were issued related to fire drills and emergency evacuation drills. The provider did not ensure quarterly fire drills with employees and residents, including nighttime simulations, nor semi-annual tornado, flooding, or other emergency evacuation drills during 2022.
Deficiencies (2)
Fire drills. Fire evacuation drills shall be conducted at least quarterly with both employees and residents, including documentation of date, time, and evacuation time. Nighttime simulation drills were not conducted as required.
Other evacuation drills. Tornado, flooding, or other emergency or disaster evacuation drills shall be conducted at least semi-annually. The provider did not ensure these drills were conducted at least semi-annually during 2022.
Report Facts
Violations issued: 2
Revisit fee: 200
Fire drills reviewed: 3
Severe weather/disaster drills performed: 1
Census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S. Maintenance Director | Maintenance Director | Discussed fire drill and emergency drill deficiencies with surveyor and acknowledged issues |
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