Deficiencies per Year
16
12
8
4
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 15, 2025
Visit Reason
A complaint investigation and verification visit was conducted on September 15, 2025, to determine if The Courtyard at Fitchburg 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 #WYGZ14) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a forfeiture of $1200.00. A verification visit was also conducted on September 15, 2025, to determine if prior violations were corrected, with an inspection fee of $200 imposed.
Complaint Details
The visit was complaint-related, resulting in issuance of SOD #WYGZ14 for violations. The Department imposed a forfeiture of $1200.00 for these violations. A verification visit was conducted to confirm correction of prior violations in SOD #WYGZ13.
Report Facts
Forfeiture amount: 1200
Reduced forfeiture amount: 780
Forfeiture amount: 400
Forfeiture amount: 800
Inspection fee: 200
Compliance timeframe: 45
Payment timeframe: 10
Payment timeframe: 10
Payment timeframe: 10
Posting duration: 90
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: 33
Capacity: 72
Deficiencies: 2
Sep 15, 2025
Visit Reason
Surveyors conducted 2 complaint investigations and a verification visit at The Courtyard at Fitchburg Assisted Living from 09/12/2025 to 09/15/2025. One complaint was substantiated and one was unsubstantiated.
Findings
Two deficiencies were identified, both repeat violations related to failure to complete assessments when there was a change in resident needs and failure to monitor and document communication with the resident's physician regarding significant health changes. The provider refused to accept Resident 22 back after hospitalization until completion of inpatient rehab, without reassessing the resident prior to rehab admission. There was also failure to notify the physician of high blood sugar and blood pressure readings.
Complaint Details
One complaint was substantiated regarding the provider's refusal to accept Resident 22 back after hospitalization without reassessment and appropriate coordination of care. One complaint was unsubstantiated.
Deficiencies (2)
| Description |
|---|
| Failure to ensure an assessment for Resident 22 was completed when there was a change in needs, including prior to admission to inpatient rehab. |
| Failure to monitor Resident 22's health adequately and document communication with the physician regarding high blood sugar and blood pressure readings. |
Report Facts
Revisit fee: 200
Deficiencies identified: 2
Blood sugar occurrences: 1
Blood pressure occurrences: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional VP of Operations B | Interviewed regarding Resident 22's discharge and refusal to accept resident back | |
| Regional Wellness Director C | Interviewed regarding Resident 22's condition and reassessment | |
| Social Worker SS | Provided discharge planning notes and interview about Resident 22's medical stability and provider refusal | |
| Family Member PP | Provided emails and interviews regarding Resident 22's discharge and care coordination | |
| Regional Wellness Director RR | Mentioned in relation to Resident 22's discharge and refusal to accept resident back | |
| LPN Supervisor QQ | Provided hospital voicemail information about Resident 22 |
Inspection Report
Enforcement
Deficiencies: 3
Jun 26, 2025
Visit Reason
Verification visits were conducted on June 26, 2025, to determine if Courtyard at Fitchburg Assisted Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities (CBRF). The document serves as a Notice of Violation and Order related to regulatory noncompliance.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in an extended order not to admit new or additional residents, imposition of a forfeiture totaling $3,400, and special orders including submission of a Resident Relocation Plan. A revisit fee of $200 was also assessed to verify correction of prior deficiencies.
Deficiencies (3)
| Description |
|---|
| Violation of DHS Code 83.14(2)(a) |
| Violation of DHS Code 83.32(3)(h) |
| Violation of DHS Code 83.35(3)(d) |
Report Facts
Forfeiture amount: 3400
Reduced forfeiture amount: 2210
Revisit inspection fee: 200
Days to pay forfeiture: 10
Days to pay revisit fee: 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: 38
Capacity: 72
Deficiencies: 5
Jun 26, 2025
Visit Reason
Surveyors conducted a verification visit and self-report review at Courtyard at Fitchburg Assisted Living to assess compliance with laws governing the Community-Based Residential Facility (CBRF) and to verify correction of previous deficiencies.
Findings
Five deficiencies were identified, three of which were repeat violations. The facility failed to comply with laws governing the CBRF, including medication administration errors, failure to update individual service plans, and inadequate documentation of medication administration. An order was issued to not admit new residents until all violations were corrected.
Deficiencies (5)
| Description |
|---|
| Failure to comply with all laws governing the CBRF, including repeat violations. |
| Residents did not receive medications at prescribed intervals; medication errors occurred including sending incorrect medications with residents on outings. |
| Individual service plans were not updated annually or when there were changes in resident needs, including failure to update fall risk interventions. |
| Medication errors or adverse reactions were not reported immediately to licensed practitioners or pharmacists. |
| Documentation of medication administration was inaccurate; medications were documented as administered when unavailable. |
Report Facts
Deficiencies identified: 5
Repeat deficiencies: 3
Revisit fee: 200
Residents present (census): 38
Total licensed capacity: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Vice President of Operations B | Regional Vice President of Operations | Interviewed regarding investigation and licensing status. |
| Regional Wellness Director C | Regional Wellness Director | Interviewed regarding medication errors, licensing, and corrective actions. |
| Executive Director F | Executive Director | Interviewed regarding investigation and corrective actions. |
| Med Tech NN | Medication Technician | Interviewed regarding medication administration errors. |
| Wellness Director W | Wellness Director | Involved in medication packing and communication with resident's family. |
| Pharmacist OO | Pharmacist | Interviewed regarding medication deliveries and availability. |
| Med Technician R | Medication Technician | Observed assisting Resident 6 and discussed fall risk. |
| Regional RN C | Regional Registered Nurse | Interviewed regarding notification of medication errors to physician. |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
May 23, 2025
Visit Reason
Surveyors conducted a complaint investigation at Courtyard at Fitchburg Assisted Living from 05/19/2025 to 05/23/2025 based on a complaint received.
Findings
Two deficiencies were identified related to the failure to include all resident needs and service frequencies in the individual service plan (ISP) and failure to monitor and document physical health and wound care for a resident with a diabetic foot ulcer. The complaint was unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated.
Deficiencies (2)
| Description |
|---|
| The provider did not ensure 1 of 2 residents reviewed had an individual service plan (ISP) that included all needs of the resident and the frequency and approaches in which services would be provided. |
| The provider did not ensure 1 of 2 residents reviewed had their physical health monitored and changes documented in his/her record. The provider did not monitor or care for Resident 1's wound. |
Report Facts
Census: 33
Deficiencies identified: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Interviewed regarding Resident 1's private care providers and ISP deficiencies | |
| RN B | Registered Nurse | Interviewed regarding Resident 1's private care providers, wound care responsibilities, and ISP deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 23, 2025
Visit Reason
A complaint investigation was conducted on May 23, 2025, to determine if Courtyard at Fitchburg Assisted Living was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department of Health Services issued a Statement of Deficiency (SOD #93YW11) identifying violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A forfeiture of $200 was imposed, and the facility was placed on a probationary license requiring correction of all violations prior to June 30, 2025.
Complaint Details
The complaint investigation concluded that the facility was not in substantial compliance with applicable statutes and administrative codes, resulting in a Statement of Deficiency and enforcement actions including a forfeiture and probationary license.
Report Facts
Forfeiture amount: 200
Reduced forfeiture amount: 130
Probationary license expiration date: Jun 30, 2025
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
Deficiencies: 0
Apr 22, 2025
Visit Reason
Six complaint investigations and a verification visit were conducted to determine if The Courtyard at Fitchburg 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 #WYGZ12) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A total forfeiture of $4,810.00 was imposed for these violations, and the facility was placed on probationary license with an order not to admit new residents until compliance is achieved.
Complaint Details
The visit was complaint-related, involving six complaint investigations and a verification visit to assess compliance. Specific substantiation status is not stated.
Report Facts
Forfeiture amount: 4810
Reduced forfeiture amount: 3126.5
Forfeiture amounts by tag: 760
Forfeiture amounts by tag: 300
Forfeiture amounts by tag: 300
Forfeiture amounts by tag: 450
Forfeiture amounts by tag: 1000
Forfeiture amounts by tag: 2000
Inspection fee: 200
Appeal filing deadline: 10
Forfeiture payment deadline: 10
Revisit fee payment deadline: 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
Census: 43
Capacity: 72
Deficiencies: 16
Mar 21, 2025
Visit Reason
Surveyor conducted a verification visit and complaint investigations at The Courtyard At Fitchburg Assisted Living due to concerns including abuse, neglect, medication administration, call light response times, and housekeeping.
Findings
Sixteen deficiencies were identified including neglect of residents, failure to report incidents timely, medication administration errors, inadequate supervision, and poor housekeeping. Several residents experienced falls and were not assisted or monitored properly. Staff were verbally aggressive and disrespectful to residents and each other.
Complaint Details
Six complaint investigations were substantiated. Issues included abuse and neglect, failure to report incidents timely, medication errors, inadequate call light response, incomplete care and housekeeping services, and multiple resident falls.
Deficiencies (16)
| Description |
|---|
| Caregiver failed to investigate and report abuse and neglect of a resident. |
| Provider did not send a written report to the Department within 3 working days after law enforcement was called due to an incident jeopardizing health or safety. |
| Provider did not report incidents with serious injury resulting in hospital admission within 3 working days. |
| Licensee failed to ensure facility compliance with laws. |
| Call light response times were delayed due to staffing shortages. |
| Residents did not receive timely assistance with showers, laundry, and dietary needs. |
| Medication administration errors and adverse reactions were not properly documented or reported. |
| Residents were not treated with courtesy, respect, and full recognition of dignity and individuality. |
| Staff were verbally aggressive and disrespectful to residents and each other. |
| Residents were left unattended during showers and other care activities. |
| Housekeeping services were incomplete or not timely, resulting in unsanitary conditions in resident rooms. |
| Laundry services were incomplete or delayed, causing resident distress. |
| Residents experienced multiple falls, some resulting in hospitalization, without adequate supervision or intervention. |
| Residents did not receive 30-day written notice of changes in services or charges. |
| Residents did not receive adequate and appropriate care consistent with their individual service plans. |
| Licensee failed to ensure proper supervision and compliance with laws governing the facility. |
Report Facts
Deficiencies identified: 16
Repeat deficiencies: 3
Substantiated complaints: 6
Revisit fee: 200
Census: 43
Total capacity: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Named in relation to communication and investigation of neglect and staffing concerns. |
| Nurse G | Nurse | Named in relation to communication and investigation of neglect and staffing concerns. |
| Med Technician R | Med Technician | Named in neglect investigation and medication administration discussions. |
| Med Technician U | Med Technician | Named in neglect investigation and medication administration discussions. |
| Med Technician S | Med Technician | Named in medication administration and call light response discussions. |
| Med Technician JJ | Med Technician | Named in staff altercation and call light response discussions. |
| Med Technician HH | Med Technician | Named in staff altercation and call light response discussions. |
| Med Technician II | Med Technician | Named in staff altercation and call light response discussions. |
| Med Technician HH | Med Technician | Named in staff altercation and call light response discussions. |
| Nurse G | Nurse | Named in staff altercation and call light response discussions. |
| Administrator A | Administrator | Named in staff altercation and call light response discussions. |
| Med Technician AA | Med Technician | Named in medication administration and call light response discussions. |
| Med Technician M | Med Technician | Named in medication administration and call light response discussions. |
| Med Technician EE | Med Technician | Named in feeding assistance and medication administration discussions. |
| Med Technician FF | Med Technician | Named in laundry and feeding assistance discussions. |
| Med Technician BB | Med Technician | Named in staff behavior and call light response discussions. |
| Med Technician GG | Med Technician | Named in staff behavior and call light response discussions. |
| Med Technician P | Med Technician | Named in call light response and laundry discussions. |
| Med Technician Y | Med Technician | Named in call light response and shower assistance discussions. |
| Nurse G | Nurse | Named in laundry and staff communication discussions. |
| Cook J | Cook | Named in food service and snack provision discussions. |
| Cook K | Cook | Named in food service and snack provision discussions. |
| Cook L | Cook | Named in food service and snack provision discussions. |
| Concierge Q | Concierge | Named in resident supervision and fall incident discussions. |
| Friend N | Family Member | Named in resident care and hygiene concerns. |
| Friend MM | Family Member | Named in resident care and hygiene concerns. |
| Friend DD | Family Member | Named in resident care and laundry concerns. |
| POA V | Power of Attorney | Named in resident care and medication concerns. |
| POA Z | Power of Attorney | Named in resident care and medication concerns. |
| POA H | Power of Attorney | Named in resident fall and medication concerns. |
Inspection Report
Routine
Census: 43
Deficiencies: 5
Jan 28, 2025
Visit Reason
Surveyors conducted a standard survey at Courtyard at Fitchburg Assisted Living, a CBRF in Fitchburg, from 01/27/2025 to 01/28/2025 to assess compliance with regulatory requirements.
Findings
Five deficiencies were identified including medication administration errors, failure to reassess resident needs after falls, incomplete individual service plans for PRN psychotropic medications, inadequate documentation of medication administration, and insufficient health monitoring and documentation of blood sugars.
Deficiencies (5)
| Description |
|---|
| Resident 1 did not receive Humalog insulin as prescribed 28 times from 12/03/2024 to 01/27/2025, with multiple documented dosing errors. |
| Resident 2's physical condition and needs were not reassessed after sustaining multiple falls in December 2024. |
| Resident 1's individual service plan did not include rationale or detailed description of behaviors for PRN psychotropic medication Olanzapine. |
| Medication administration documentation was incomplete for 3 of 4 residents, including undocumented insulin doses and administration of medication not available in the medication cart. |
| Resident 1 and Resident 3's blood sugars were not consistently monitored or documented as ordered, with multiple missing blood sugar records. |
Report Facts
Deficiencies identified: 5
Medication administration errors: 28
Medication unavailable occurrences: 25
Insulin administrations without blood sugar documentation: 63
Insulin administrations documented: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Reviewed insulin administration concerns and follow-up with surveyors. | |
| Regional Vice President B | Discussed insulin administration auditing and documented surveyor concerns. | |
| Regional Nurse C | Discussed insulin administration auditing and facility nurse responsibilities. | |
| Caregiver D | Provided information about medication cart and medication availability. | |
| Pharmacy E | Confirmed pharmacy had not provided medication due to lack of prior authorization. |
Inspection Report
Routine
Deficiencies: 0
Jan 28, 2025
Visit Reason
A standard survey was conducted on January 28, 2025, to determine if Courtyard at Fitchburg 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 #WYGZ11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation, an Order to Comply, and a Probationary License with imposed forfeitures totaling $2400.00.
Report Facts
Forfeiture amount: 2400
Forfeiture amount: 700
Forfeiture amount: 1200
Forfeiture amount: 500
Forfeiture amount: 1560
Compliance timeframe: 45
Payment timeframe: 10
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 |
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