Inspection Reports for The Auberge at Oak Village
W128 N6900 Northfield Drive, Menomonee Falls, WI 53051, WI, 53051
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
73% occupied
Based on a April 2025 inspection.
Census over time
Inspection Report
Enforcement
Deficiencies: 0
Apr 29, 2025
Visit Reason
A verification visit was conducted on April 29, 2025, to determine if Auberge at Oak Village a Memory Care Community 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 Notice of Violation, Order to Comply, Special Orders to protect resident privacy, and an imposed forfeiture totaling $3,940.00. The licensee must comply immediately and achieve substantial compliance within 45 days.
Report Facts
Forfeiture amount: 3940
Reduced forfeiture amount: 2561
Forfeiture by tag N 352: 1640
Forfeiture by tag N 357: 500
Forfeiture by tag N 389: 1800
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: 41
Capacity: 56
Deficiencies: 3
Apr 29, 2025
Visit Reason
The Bureau of Assisted Living conducted a verification visit of a previous statement of deficiency (SOD 3GKY11) at Auberge At Oak Village A Memory Care Community to assess correction of cited deficiencies.
Findings
Three repeat citations of noncompliance were issued related to residents not receiving prescribed medications as ordered, violation of residents' rights regarding recording and filming, and failure to update individual service plans (ISPs) to reflect changes in residents' needs and conditions.
Deficiencies (3)
| Description |
|---|
| Residents 14, 15, 16, and 18 did not receive all prescribed medications in the dosage and at intervals prescribed by a practitioner, including polyethylene glycol, lidocaine patches, and metoprolol. |
| The provider did not ensure residents' right not to be recorded or filmed was respected when an electronic surveillance camera remained in a common space without proper notification. |
| Resident 18's and Resident 19's individual service plans were not updated to reflect changes in their needs, including use of tubigrips, fall status, use of broda chair, hoyer lift, hospice involvement, and other care needs. |
Report Facts
Revisit fee: 200
Residents served: 41
Licensed capacity: 56
Medication doses administered: 101
Medication doses administered: 49
Medication doses administered: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R. (Licensed Practical Nurse) | Health Services Director (HSD) | Provided records and information related to medication administration and resident care |
| F. (Resident Care Coordinator) | Resident Care Coordinator (RCC) | Provided information about medication administration and resident care |
| T. (Caregiver) | Caregiver | Provided information about Resident 19's care and mobility |
| A. (Administrator) | Administrator | Interviewed regarding camera use and noncompliance corrections |
Inspection Report
Enforcement
Deficiencies: 0
Sep 24, 2024
Visit Reason
The inspection was conducted to determine if Auberge at Oak Village a Memory Care Community was in substantial compliance with Wisconsin Statutes chapter 50 and Administrative Code chapter DHS 83, which regulate community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #3GKY11) identifying 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, health monitoring, and resident care, and a forfeiture of $3,960 was imposed for specific violations.
Report Facts
Forfeiture amount: 3960
Forfeiture amount: 2760
Forfeiture amount: 200
Forfeiture amount: 1000
Compliance timeframe: 45
Compliance timeframe: 10
Compliance timeframe: 7
Payment timeframe: 10
Reduced forfeiture amount: 2574
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: 46
Capacity: 56
Deficiencies: 6
Sep 18, 2024
Visit Reason
The Bureau of Assisted Living conducted a standard licensing survey and a complaint investigation at Auberge At Oak Village A Memory Care Community following allegations of medication administration issues and other concerns.
Findings
The provider failed to ensure residents received all prescribed medications as ordered, failed to protect residents' privacy regarding electronic surveillance cameras, did not follow individual service plans for assistance with meals, failed to update service plans after changes in resident condition, did not adequately monitor resident health leading to serious infection and maggot infestation, and did not maintain a clean and homelike environment.
Complaint Details
The complaint was substantiated based on findings of medication administration failures, privacy violations, inadequate health monitoring, and environmental cleanliness issues.
Deficiencies (6)
| Description |
|---|
| Resident 1, Resident 2, Resident 3, Resident 4, and Resident 6 did not receive all prescribed medications in the dosage and at intervals prescribed by a practitioner. |
| Residents were recorded and filmed in a large common space and sunroom without informed consent, violating privacy rights. |
| Resident 6 did not receive hands-on assistance while eating breakfast as indicated on the individual service plan. |
| Resident 5's individual service plan was not updated to reflect changes in mobility and dietary needs. |
| Resident 1's health was not adequately monitored, resulting in failure to identify and address cellulitis, maggot infestation, and infected groin rash prior to hospitalization. |
| The living environment was not maintained in a safe, clean, and homelike condition, including dirty refrigerators, exposed electrical wires, soiled shower chairs, food debris, and dust accumulation. |
Report Facts
Citations of noncompliance: 6
Facility licensed capacity: 56
Resident census: 46
Missed doses of medications: 10
Missed doses of medications: 5
Missed doses of medications: 15
Missed doses of medications: 19
Missed doses of medications: 21
Potential doses administered: 93
Potential doses administered: 69
Potential doses administered: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver F | Former Residential Care Coordinator | Interviewed regarding medication administration failures and Resident 1's condition. |
| Administrator A | Interviewed regarding medication availability, surveillance cameras, health monitoring, and environmental concerns. | |
| Regional Facility RN B | Regional Facility Registered Nurse | Interviewed regarding medication administration, health monitoring, and surveillance cameras. |
| Caregiver G | Interviewed regarding Resident 1's care and observations on 07/31/2024. | |
| Pharmacy Staff H | Interviewed regarding medication orders and deliveries for Residents 2 and 3. | |
| Pharmacy Staff I | Interviewed regarding medication orders and deliveries for Resident 4. | |
| Caregiver N | Interviewed regarding feeding assistance for Resident 6. | |
| Hospice RN J | Hospice Registered Nurse | Interviewed regarding hospice care and observations of Resident 1. |
| Hospice LPN K | Hospice Licensed Practical Nurse | Interviewed regarding hospice care and wound treatment for Resident 1. |
| Environment Services Director D | Environmental Services Director | Interviewed regarding surveillance cameras and environmental cleanliness. |
| Housekeeper E | Interviewed regarding cleaning and observations of maggots in Resident 1's wheelchair. | |
| Resident Care Coordinator C | Mentioned in relation to medication cart audits and communication. | |
| Former Facility Nurse M | Mentioned regarding lack of communication about medication availability. |
Inspection Report
Follow-Up
Census: 47
Deficiencies: 0
May 16, 2023
Visit Reason
The Bureau of Assisted Living, Southern Regional Office conducted a verification visit of statement of deficiency 11U911 at Auberge At Oak Village A Memory Care Community.
Findings
No citations of noncompliance were issued. The noncompliance cited in SOD 11U911 was substantially corrected.
Report Facts
Revisit fee: 200
Notice
Deficiencies: 0
Feb 27, 2023
Visit Reason
Complaint investigations were concluded to determine if Auberge at Oak Village a Memory Care Community 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 as detailed in Statement of Deficiency #11U911, resulting in an imposed forfeiture of $900.00 and an order to comply with requirements within 45 days.
Complaint Details
Complaint investigations were concluded on February 27, 2023, to determine compliance. Violations were found and substantiated as per the enclosed Statement of Deficiency #11U911.
Report Facts
Forfeiture amount: 900
Reduced forfeiture amount: 585
Compliance timeframe: 45
Payment timeframe: 10
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: 38
Deficiencies: 1
Feb 20, 2023
Visit Reason
The Bureau of Assisted Living conducted three complaint investigations at Auberge At Oak Village A Memory Care Community based on allegations of significant skin breakdown resulting in a resident's hospitalization.
Findings
The provider failed to ensure Resident 1 received prompt and adequate treatment for multiple wounds, including left heel, right heel, and right buttock wounds, which worsened due to delayed physician orders and poor communication with home care agencies. Resident 1 was hospitalized for wound evaluation and treatment, including invasive procedures, and returned with ongoing wound care needs.
Complaint Details
One of three complaints was substantiated related to significant skin breakdown resulting in Resident 1's hospitalization.
Deficiencies (1)
| Description |
|---|
| Failure to ensure Resident 1 received prompt and adequate treatment appropriate to Resident 1's needs, resulting in worsening skin breakdown and hospitalization. |
Report Facts
Census: 38
Wound size: 6
Wound size: 4
Wound size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Facility Nurse B | Registered Nurse | Conducted pre-admission assessment, documented wound care, communicated with home care agencies and family, and provided wound treatment documentation. |
| Caregiver F | Provided care to Resident 1, reported skin breakdown, and described mobility and positioning practices. | |
| Home Care Nurse C | Provided wound treatment including wound vac changes and Foley catheter management after Resident 1's hospitalization. | |
| Practitioner I | Physician | Evaluated Resident 1 on 01/26/2023 and wrote orders for wound care and home care agency evaluation. |
| Family Member P | Reported observations of Resident 1's wound condition and feeding difficulties. | |
| Legal Representative G | Resident 1's legal representative involved in care decisions and communication with facility and home care agencies. | |
| Facility Licensed Practical Nurse E | Licensed Practical Nurse | Observed Resident 1's wound condition and called for hospital transfer. |
| Resident Care Coordinator, RCC L | Communicated with home care agencies regarding wound care referral and family concerns. |
Loading inspection reports...
