Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
23 residents
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 0
Feb 11, 2025
Visit Reason
Surveyor conducted a standard survey and complaint investigation at Sunset Ridge Jefferson.
Findings
No deficiencies were identified. The complaint was unsubstantiated.
Complaint Details
The complaint was investigated and found to be unsubstantiated.
Report Facts
Census: 23
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 0
Apr 3, 2024
Visit Reason
Surveyor conducted a complaint investigation and verification visit for statement of deficiency (SOD) 61OL11 and SOD T3OE11 at Sunset Ridge Jefferson.
Findings
No deficiencies were identified; 14 previous deficiencies were substantially corrected. The complaint was unsubstantiated.
Complaint Details
The complaint was unsubstantiated.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 20, 2023
Visit Reason
A complaint investigation was conducted on 11/20/2023 to determine if Sunset Ridge Jefferson was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #T3OE11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in an imposed forfeiture of $800.00 for specific code violations.
Complaint Details
Complaint investigation concluded on 11/20/2023. The Department determined violations of state statutes and administrative codes, leading to enforcement action.
Deficiencies (2)
| Description |
|---|
| Violation of DHS Code 83.35(3)(a) |
| Violation of DHS Code 83.37(3)(d) |
Report Facts
Forfeiture amount: 800
Forfeiture amount per violation: 400
Forfeiture amount per violation: 400
Reduced forfeiture amount: 520
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: 23
Deficiencies: 3
Nov 20, 2023
Visit Reason
Surveyor conducted a complaint investigation at Sunset Ridge Jefferson following a complaint received on 09/26/2023 regarding resident supervision and well-being.
Findings
Three deficiencies were identified related to failure to investigate injuries of unknown source, failure to develop a comprehensive individualized service plan for a resident at risk of falls, and failure to properly document medication administration. The complaint was substantiated.
Complaint Details
Complaint was substantiated. The complaint involved resident supervision and well-being, specifically regarding injuries of unknown source and medication administration errors.
Deficiencies (3)
| Description |
|---|
| Provider did not investigate Resident 1's injuries that were not observed by any person after s/he was found on the ground in the bathroom with blood on his/her face. |
| Provider did not develop an individualized service plan for Resident 1 to identify his/her needs, desired outcomes, program services, frequency and approaches regarding falls. |
| Provider did not ensure staff initialed Resident 1's medication administration record at the time of medication administration, and documentation of medication administration was incomplete. |
Report Facts
Deficiencies cited: 3
Resident admission date: Jun 21, 2023
Resident fall report date: Sep 26, 2023
Complaint received date: Sep 26, 2023
Complaint investigation date: Nov 8, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Admin B | Assistant Administrator | Interviewed regarding Resident 1's injuries, individualized service plan, and medication errors. |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 26
Deficiencies: 11
Aug 17, 2023
Visit Reason
On 08/09/2023, a surveyor conducted 4 complaint investigations at Sunset Ridge Jefferson related to supervision and resident elopement during a severe storm.
Findings
Eleven deficiencies were identified, including failure to report resident whereabouts, inadequate staff training and supervision, and failure to maintain a safe environment. All 4 complaints were substantiated.
Complaint Details
Four complaints were investigated and all were substantiated. Complaints involved supervision failures, resident elopement, and staff training deficiencies.
Deficiencies (11)
| Description |
|---|
| Failure to report when resident's whereabouts were unknown. |
| Failure to notify resident's legal representative and physician of incidents or changes. |
| Licensee did not ensure facility compliance with laws including staff training and supervision. |
| Inadequate staff training and competency; multiple caregivers lacked required training in fire safety, medication administration, first aid, and client group management. |
| Inadequate employee supervision; caregivers worked alone without proper oversight. |
| Failure to maintain a safe, clean, and comfortable environment; weekly menus were not available to residents. |
| Failure to assess resident for risks including elopement; Resident 3 was found wandering outside unattended. |
| Failure to provide adequate supervision to meet resident needs; Resident 3 left facility unattended. |
| Failure to provide adequate nutrition menus and meal service. |
| Failure to provide a safe, clean, comfortable, and homelike environment for all residents. |
| Failure to provide adequate supervision and training to staff to meet resident needs. |
Report Facts
Deficiencies identified: 11
Repeat deficiencies: 4
Census: 20
Total capacity: 26
Wind speed: 95
Temperature: 90
Staff shifts with only one caregiver: 43
Staff shifts with untrained caregivers: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Admin B | Assistant Administrator | Interviewed regarding resident elopement, staff training, and supervision deficiencies |
| Licensee/Administrator A | Licensee/Administrator | Interviewed regarding incident reporting, staff training, supervision, and complaint follow-up |
| Caregiver C | Caregiver | Interviewed regarding resident elopement, supervision, and incident reporting |
| Caregiver J | Caregiver | Named in findings related to staff training deficiencies |
| Caregiver D | Caregiver | Named in findings related to staff training deficiencies |
| Caregiver E | Caregiver | Named in findings related to staff training deficiencies |
| Caregiver F | Caregiver | Named in findings related to staff training deficiencies |
| Caregiver G | Caregiver | Named in findings related to staff training deficiencies and supervision |
| Caregiver K | Caregiver | Named in findings related to resident verbal abuse and neglect allegations |
| Resident 3 | Resident involved in elopement and supervision incidents | |
| Resident 1 | Resident involved in verbal abuse and neglect allegations | |
| Friend L | Resident's friend involved in verbal abuse and neglect allegations |
Inspection Report
Complaint Investigation
Deficiencies: 7
Aug 17, 2023
Visit Reason
Four complaint investigations were concluded for Sunset Ridge Jefferson 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 #61OL11) citing multiple violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in an order to comply, a prohibition on admitting new residents, and a forfeiture of $3,460.00.
Complaint Details
Four complaint investigations were concluded on 08/17/2023 to assess compliance with applicable statutes and administrative codes. The violations were substantiated as indicated by the issuance of the Statement of Deficiency and enforcement actions.
Deficiencies (7)
| Description |
|---|
| Violation of Wis. Admin. Code § DHS 83.14(2)(a) related to facility operation and compliance |
| Violation of Wis. Admin. Code § 83.12(4)(a) |
| Violation of Wis. Admin. Code § 83.12(5)(a) |
| Violation of Wis. Admin. Code § 83.20(2)(a-d) |
| Violation of Wis. Admin. Code § 83.23 |
| Violation of Wis. Admin. Code § 83.35(1)(c) |
| Violation of Wis. Admin. Code § 83.38(1)(b) |
Report Facts
Forfeiture amount: 3460
Reduced forfeiture amount: 2249
Forfeiture amounts by tag: 1000
Forfeiture amounts by tag: 150
Forfeiture amounts by tag: 150
Forfeiture amounts by tag: 400
Forfeiture amounts by tag: 860
Forfeiture amounts by tag: 300
Forfeiture amounts by tag: 600
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: 19
Deficiencies: 0
Apr 4, 2023
Visit Reason
Surveyor conducted a verification visit to Sunset Ridge Jefferson to assess correction of previous deficiencies.
Findings
No deficiencies were identified during the visit; 8 previous deficiencies were substantially corrected.
Report Facts
Revisit fee: 200
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