Inspection Reports for The Arboretum Senior Living
W180 N7890, Town Hall Rd, Menomonee Falls, WI 53051, United States, WI, 53051
Back to Facility ProfileDeficiencies per Year
4
3
2
1
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 12, 2025
Visit Reason
A standard survey and a complaint investigation were conducted to determine if The Arboretum was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #E63H11) for violations of Wisconsin statutes and administrative codes related to the operation of the facility. The licensee was ordered to comply with requirements, implement corrective measures, and provide staff training. A forfeiture of $650 was imposed for specific violations.
Complaint Details
The visit was triggered by a complaint investigation combined with a standard survey to assess compliance with applicable statutes and administrative codes.
Deficiencies (1)
| Description |
|---|
| Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #E63H11 |
Report Facts
Forfeiture amount: 650
Reduced forfeiture amount: 422.5
Forfeiture amount: 500
Forfeiture amount: 150
Compliance timeframe: 45
Payment timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 18, 2025
Visit Reason
A complaint investigation was conducted to determine if the Arboretum 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 #CEU011) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation and an imposed forfeiture totaling $650.00 for specific code violations.
Complaint Details
The visit was complaint-related and concluded on March 18, 2025. The Department determined violations of applicable statutes and codes, issuing a Statement of Deficiency and enforcement actions.
Deficiencies (2)
| Description |
|---|
| Violation of DHS Code 83.37(2)(d) |
| Violation of DHS Code 83.38(1)(g) |
Report Facts
Forfeiture amount: 650
Forfeiture amount (reduced): 422.5
Forfeiture for violation N418: 150
Forfeiture for violation N432: 500
Compliance timeframe: 45
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: 42
Deficiencies: 3
Mar 18, 2025
Visit Reason
Surveyor conducted a complaint investigation at The Arboretum following a complaint alleging care concerns and cleanliness issues.
Findings
Three deficiencies were identified including improper documentation of medication administration, inadequate health monitoring related to blood sugar and skin issues, and failure to maintain clean and odor-free resident rooms. The complaint was substantiated with evidence of missing medication records, unreported high blood sugar readings, skin issues not documented, and multiple cleanliness concerns in resident rooms.
Complaint Details
The complaint was substantiated. It included allegations of care concerns such as medication errors, inadequate health monitoring, and cleanliness issues in the facility.
Deficiencies (3)
| Description |
|---|
| Improper documentation within the Medication Administration Record (MAR) for Resident 1, with 5 blanks over 33 days where scheduled insulin should have been documented. |
| Failure to monitor Resident 1's health adequately, including not reporting 20 blood glucose readings over 300 and 4 over 400 to the physician, and lack of documentation of a significant rash and UTI after discharge. |
| Rooms not kept clean and free from odors, with multiple resident rooms observed to have food crumbs, fecal matter stains, soiled clothing, and urine odors. |
Report Facts
Deficiencies identified: 3
Missing medication documentation: 5
Blood glucose readings over 300: 20
Blood glucose readings over 400: 4
Resident census: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON A | Director of Nursing | Interviewed regarding missing insulin documentation and health monitoring concerns for Resident 1, acknowledged deficiencies. |
| Charge Nurse E | Charge Nurse | Interviewed regarding cleanliness concerns observed during the facility tour. |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 3
Dec 10, 2024
Visit Reason
The Bureau of Assisted Living conducted a complaint investigation and standard licensing survey at Arboretum (The) following a complaint. The investigation included review of resident care and facility conditions.
Findings
Three deficiencies were identified including failure to provide prompt and adequate treatment for a resident's thumb fracture, failure to document medication administration properly, and failure to maintain a clean and homelike environment with several maintenance issues observed.
Complaint Details
The complaint was unsubstantiated.
Deficiencies (3)
| Description |
|---|
| Failure to ensure Resident 1 received prompt and adequate treatment related to a left thumb proximal phalanx fracture, with a delay of approximately 5 hours before clinical assessment. |
| Failure to ensure that the person administering Resident 4's medications or treatments initialed the medication administration record after administration, a repeat violation. |
| Failure to maintain a clean and homelike environment, including dusty air vent, unlit exit sign, unsecured and missing heat register covers, and scuffed carpet in resident rooms. |
Report Facts
Deficiencies identified: 3
Delay in treatment: 5
Resident census: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charge Nurse F | Licensed Practical Nurse (LPN) | Assessed Resident 1's thumb approximately 5 hours after concern was known. |
| Health Services Director B | Registered Nurse (RN) | Oversaw health services and acknowledged delay in treatment and documentation issues. |
| Caregiver E | Reported unaware of Resident 1's fall and notified Resident Care Coordinator D about the thumb concern. | |
| Resident Care Coordinator D | Inspected Resident 1's thumb and informed Health Services Director B about the concern. | |
| Executive Director A | Reviewed environmental concerns and facility maintenance issues with surveyors. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 14, 2024
Visit Reason
A complaint investigation was conducted at The Arboretum, a CBRF located in Menomonee Falls, WI.
Findings
As a result of the investigation, zero violations of Chapter DHS 83 were issued and the complaint was unsubstantiated.
Complaint Details
The complaint was unsubstantiated with zero violations issued.
Report Facts
Violations issued: 0
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Apr 9, 2024
Visit Reason
Surveyor conducted a verification visit and complaint investigation at The Arboretum.
Findings
No deficiencies were identified; three previous deficiencies were substantially corrected. The complaint was unsubstantiated.
Complaint Details
The complaint was unsubstantiated.
Report Facts
Revisit fee: 200
Census: 42
Inspection Report
Complaint Investigation
Census: 42
Capacity: 78
Deficiencies: 3
Sep 15, 2023
Visit Reason
Surveyor conducted a complaint investigation at The Arboretum following a complaint alleging a medication error involving morphine.
Findings
Three deficiencies were identified related to medication administration errors, including a wrong medication given to a resident and lack of proper documentation. The complaint was substantiated.
Complaint Details
Complaint alleging medication error with morphine was received on 08/15/2023. Investigation conducted on 09/06/2023. Complaint was substantiated.
Deficiencies (3)
| Description |
|---|
| Provider did not ensure Resident 1 received prescribed morphine or lorazepam as ordered near end of life. |
| Medication error or adverse reaction: Resident 1 was administered Resident 2's haldol in error; not documented in Resident 1's record. |
| Documentation of medication administration was incomplete; Charge Nurse C did not document medication administration or side effects after administering wrong medication or PRN medication. |
Report Facts
Deficiencies identified: 3
Census: 42
Total capacity: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charge Nurse C | Charge Nurse | Named in medication error involving administration of wrong medication and documentation deficiencies |
| Health Services Director B | Health Services Director | Provided incident root cause analysis and interviewed regarding medication error |
| Caregiver D | Caregiver | Medication passer involved in the incident and interviewed about awareness of medication error |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 15, 2023
Visit Reason
A complaint investigation was conducted to determine if The Arboretum 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 #GUIE11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a $200 forfeiture imposed on the licensee.
Complaint Details
The complaint investigation concluded that the facility was not in substantial compliance with applicable statutes and administrative codes, leading to the issuance of a Statement of Deficiency and enforcement action.
Deficiencies (1)
| Description |
|---|
| Violation of DHS Code 83.32(3)(h) as identified in SOD #GUIE11 |
Report Facts
Forfeiture amount: 200
Reduced forfeiture amount: 130
Compliance timeframe: 45
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: 42
Deficiencies: 0
Apr 18, 2023
Visit Reason
Surveyor conducted a verification visit at The Arboretum to verify correction of previous deficiencies.
Findings
No deficiencies were identified during this visit; two previous deficiencies were substantially corrected from the prior statement of deficiency dated 01/18/2023.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 18, 2023
Visit Reason
A standard survey, verification visit, and complaint investigation were conducted on 01/18/2023 to determine if The Arboretum was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued Statement of Deficiency (SOD) #7DU112 for violations found during the inspection. A subsequent verification visit on 01/18/2023 confirmed correction of violations contained in SOD #7DU111. An inspection fee of $200 is being assessed for the revisit.
Complaint Details
The visit included a complaint investigation. The report does not specify substantiation status.
Report Facts
Inspection fee: 200
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
Complaint Investigation
Census: 41
Deficiencies: 2
Jan 17, 2023
Visit Reason
Surveyor conducted a complaint investigation, verification visit, and probationary survey on 01/17/2023.
Findings
Two deficiencies were identified related to psychotropic medication use and proof-of-use records. The complaint was unsubstantiated, but the provider failed to include rationale and detailed descriptions for PRN psychotropic medication use in residents' service plans and did not ensure monthly monitoring or proper documentation of proof-of-use records.
Complaint Details
The complaint was unsubstantiated. One previous deficiency was substantially corrected from a prior statement of deficiency dated 08/23/2022. A $200.00 revisit fee is being assessed under Wis. Stat. Ch. 50.
Deficiencies (2)
| Description |
|---|
| Failure to include rationale and detailed description of behaviors indicating need for PRN psychotropic medication in Residents 1 and 2's individualized service plans and failure to monitor monthly for inappropriate use. |
| Failure to maintain and audit proof-of-use records for schedule II drugs, specifically for Resident 2's lorazepam and morphine, including lack of administrator/designee signature and date on daily audits. |
Report Facts
Revisit fee: 200
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Reviewed monthly PRN psychotropic medication reviews and discussed concerns about documentation and audits with surveyor and Executive Director B. | |
| Executive Director B | Discussed concerns about medication documentation and audits with surveyor and Nurse D. | |
| Caregiver E | Signed Resident 2's proof-of-use records for lorazepam and morphine; no documentation of audit. |
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