Deficiencies (last 2 years)
Deficiencies (over 2 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
72% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 20, 2025
Visit Reason
A complaint investigation and standard survey were conducted to determine if Primrose of Pleasant Prairie was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #6S4C11) for violations of state statutes and administrative codes. A forfeiture of $400 was imposed for these violations, with a reduced payment option of $260 if not appealed.
Complaint Details
The visit was complaint-related, concluding a complaint investigation and standard survey to assess compliance with Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. Specific substantiation status is not stated.
Report Facts
Forfeiture amount: 400
Reduced forfeiture amount: 260
Forfeiture payment timeframe: 10
Compliance timeframe: 45
Inspection fee: 200
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: 86
Capacity: 120
Deficiencies: 7
Aug 20, 2025
Visit Reason
The surveyor completed a complaint investigation and standard survey to assess compliance with regulatory requirements at the facility.
Findings
Seven deficiencies were identified including failure to obtain timely communicable disease screenings for employees, inadequate continuing education for staff, incomplete resident evacuation evaluations, unsecured toxic substances, and failure to conduct required fire and emergency evacuation drills in 2024.
Complaint Details
The complaint investigation was unsubstantiated despite identification of seven deficiencies during the survey.
Deficiencies (7)
| Description |
|---|
| Employees were not screened for communicable diseases including tuberculosis within 90 days before employment for 2 of 2 caregivers reviewed. |
| Two of three caregivers did not receive the required 15 hours of continuing education in 2024. |
| Two of four residents were not evaluated within 3 days of admission for evacuation limitations using the department's form. |
| One of two residents was not evaluated annually in 2024 for mental or physical capability to respond to a fire alarm. |
| Cleaning compounds and toxic substances were not securely stored in 2 of 2 kitchenette areas. |
| Fire drills were not conducted quarterly in 2024; no fire drills were documented for that year. |
| Tornado, flooding, or other emergency or disaster evacuation drills were not conducted semi-annually in 2024. |
Report Facts
Deficiencies identified: 7
Census: 86
Total licensed capacity: 120
Continuing education hours: 12.38
Days late for TB test: 118
Fire drills conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver C | Named in deficiency for lack of communicable disease screening and late TB test. | |
| Caregiver D | Named in deficiency for lack of communicable disease screening. | |
| Caregiver E | Named in deficiency for not receiving continuing education in 2024. | |
| Caregiver F | Certified Medication Technician | Named in deficiency for insufficient continuing education hours and lack of medication training in 2024. |
| Executive Director A | Executive Director | Interviewed and confirmed code requirements; acknowledged deficiencies. |
| Director of Nursing B | Director of Nursing | Interviewed and confirmed code requirements; reported corrective actions. |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
May 5, 2025
Visit Reason
Surveyor conducted a complaint investigation at Primrose of Pleasant Prairie, a CBRF located in Pleasant Prairie, WI.
Findings
As a result of the investigation, 0 violations of Chapter DHS 83 were issued. The complaint was unsubstantiated.
Complaint Details
The complaint was unsubstantiated.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Jul 15, 2024
Visit Reason
Surveyors completed a complaint investigation at Primrose Of Pleasant Prairie.
Findings
No deficiencies were identified and the complaint was unsubstantiated.
Complaint Details
Complaint was unsubstantiated.
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