Inspection Reports for
The Courtyard at Sussex Cbrf
W235 N6350 HICKORY DRIVE, SUSSEX, WI, 53089
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
50 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 4
Date: Aug 13, 2025
Visit Reason
Complaint investigation and verification visit conducted due to a complaint alleging inadequate supervision and fall incidents resulting in injury.
Complaint Details
Complaint alleged inadequate supervision of a resident leading to a fall with significant injury. The complaint was substantiated.
Findings
Four citations of noncompliance were issued including repeated citations related to individual service plans not being updated to reflect residents' needs and inadequate supervision leading to falls and injuries. Two residents' ISPs lacked updates on mobility, fall risk, and PRN psychotropic medication use. Resident 11 experienced an unwitnessed fall resulting in a hip fracture. Resident 12 had multiple falls and rapid decline in mobility not reflected in ISPs. Communication with physicians regarding falls and medication issues was also deficient.
Deficiencies (4)
Resident 11's and Resident 12's individual service plans were not updated to reflect changes in mobility, fall risk, and interventions.
Individual service plans for two residents prescribed PRN psychotropic medications did not include rationale for use, detailed behavior descriptions, or documentation of medication effectiveness and side effects.
Resident 11 was not provided supervision appropriate to fall risk needs, resulting in an unwitnessed fall causing a hip fracture.
Provider failed to document communication with Resident 13's physician regarding multiple falls and blood pressure issues resulting in held medication doses.
Report Facts
Fall incidents: 14
Revisit fee: 200
Fall incidents: 5
Held medication doses: 6
Fall incidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility Nurse M | Nurse | Provided information about Resident 11's condition, wheelchair use, and fall incidents. |
| Hospice Nurse X | Hospice Nurse | Provided information about Resident 11's care, safety concerns, and fall incidents. |
| Wellness Director L | Registered Nurse | Responsible for developing and updating resident ISPs; provided information on residents' care and deficiencies. |
| Administrator A | Administrator | Conducted investigation of Resident 11's fall incident and provided related statements. |
| Caregiver V | Provided information about Resident 12's decline in mobility and supervision. | |
| Caregiver W | Provided information about Resident 12's mobility and falls, and Resident 11's fall incidents. | |
| Family Member Z | Provided observations about Resident 11's behavior and supervision needs. | |
| Legal Representative AA | Involved in care conferences and supervision requests for Resident 11. | |
| Caregiver E | Involved in Resident 11's fall incident and subsequent care. | |
| Caregiver Y | Involved in Resident 11's fall incident and subsequent care. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 13, 2025
Visit Reason
A complaint investigation and verification visit were conducted on August 13, 2025, to determine if The Courtyard at Sussex CBRF was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, conducted to verify compliance with applicable statutes and administrative codes. Specific substantiation status is not stated.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation and an imposed forfeiture totaling $3,200. The licensee was ordered to comply immediately and develop corrective measures within 45 days, including procedures for health monitoring and staff training.
Report Facts
Forfeiture amount: 3200
Reduced forfeiture amount: 2080
Forfeiture amount by tag: 1400
Forfeiture amount by tag: 1000
Forfeiture amount by tag: 800
Inspection fee: 200
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
Enforcement
Deficiencies: 2
Date: Jan 9, 2025
Visit Reason
A standard survey and verification visit was conducted on January 9, 2025, to determine if Courtyard at Sussex CBRF 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 and an imposed Order to Comply. The licensee was ordered to develop or revise procedures and staff training related to health monitoring and medication management. A total forfeiture of $3,160 was imposed for multiple violations, with some accruing daily until compliance is verified.
Deficiencies (2)
Failure to ensure the administrator supervises daily operation and ensures provision of services to meet residents’ physical and mental health needs, including health monitoring and documentation.
Medication management and administration deficiencies including documentation, administration, prevention and response to medication errors, monitoring for adverse side effects, secure storage, and disposal of medications.
Report Facts
Forfeiture amount: 3160
Reduced forfeiture amount: 2054
Forfeiture by tag: 1000
Forfeiture by tag: 400
Forfeiture by tag: 200
Forfeiture by tag: 1060
Forfeiture by tag: 500
Inspection fee: 200
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
Routine
Census: 48
Deficiencies: 6
Date: Jan 7, 2025
Visit Reason
The Bureau of Assisted Living conducted a standard licensing survey and verification visit at The Courtyard At Sussex CBRF to assess compliance with regulatory requirements.
Findings
The survey identified five citations of noncompliance including caregiver training deficiencies, medication administration errors affecting multiple residents, failure to update individual service plans, and inadequate health monitoring such as bowel movement tracking and blood pressure monitoring.
Deficiencies (6)
Caregiver R did not complete required department-approved training in fire safety, first aid, and choking within 90 days of employment.
Caregiver S did not complete at least 15 hours of continuing education in 2024, missing required topics including first aid.
Residents 3, 4, 5, 6, 7, 8, and 10 did not receive all prescribed medications in the correct dosage and intervals as ordered by practitioners.
Resident 3's individual service plan was not updated to reflect rectal prolapse care needs or hospice services.
Resident 4's bowel movements were not monitored or documented to ensure medication was held as prescribed when 3 bowel movements occurred within 24 hours.
The provider did not monitor and respond to elevated blood pressure readings for Residents 9 and 10 as directed by their medical providers.
Report Facts
Citations issued: 5
Revisit fee: 200
Medication administration errors: 12
Medication doses missed: 13
Continuing education hours: 7
Medication doses administered: 189
Medication doses administered: 73
Medication doses administered: 20
Medication doses administered: 59
Medication doses administered: 160
Blood pressure readings: 27
Blood pressure readings: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver R | Named in findings for failure to complete required training. | |
| Caregiver S | Named in findings for failure to complete required continuing education. | |
| Facility Nurse M | Licensed Practical Nurse | Observed administering medications and noted in medication administration deficiencies. |
| Associate Administrator B | Interviewed regarding training records and compliance. | |
| Wellness Director L | Registered Nurse | Provided records, interviewed about medication administration and care plan deficiencies. |
| Pharmacy Staff O | Interviewed regarding medication deliveries and orders. | |
| Pharmacy Staff P | Interviewed regarding medication deliveries for Resident 7. | |
| Pharmacy Staff Q | Interviewed regarding medication deliveries for Resident 7. | |
| Caregiver N | Observed during medication pass. | |
| Caregiver H | Interviewed about bowel movement monitoring. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 15, 2024
Visit Reason
A complaint investigation was conducted on August 15, 2024, to determine if Courtyard at Sussex CBRF was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The investigation was complaint-driven and concluded on August 15, 2024. The Department issued a Statement of Deficiency and imposed enforcement actions including forfeiture.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency (SOD #ZXFY11) and imposed a forfeiture of $1200. The licensee was ordered to develop and implement corrective measures to ensure Individual Service Plans are properly created, implemented, and revised to meet residents' assessed needs.
Deficiencies (1)
Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #ZXFY11
Report Facts
Forfeiture amount: 1200
Forfeiture amount: 800
Forfeiture amount: 400
Forfeiture payment deadline days: 10
Compliance correction timeframe days: 45
Extension request timeframe days: 10
Reduced forfeiture amount: 780
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: 51
Deficiencies: 2
Date: Aug 15, 2024
Visit Reason
The Bureau of Assisted Living conducted a complaint investigation at The Courtyard At Sussex CBRF on 08/15/2024 following concerns regarding personal care services.
Complaint Details
The complaint was substantiated with two citations of noncompliance issued related to service plan updates and personal care services.
Findings
Two citations of noncompliance were issued related to failure to update individual service plans and inadequate personal care services, specifically toileting and incontinence care, for Residents 1 and 2. Both residents were not provided personal care services adequate to meet their needs, with significant delays in incontinence care and toileting assistance.
Deficiencies (2)
Resident 1's and Resident 2's individual service plans were not updated to reflect their current needs, abilities, and physical or mental condition.
Resident 1 and Resident 2 were not provided with personal care services related to toileting and incontinence care as required, with delays of approximately 5 to 6 hours between care checks.
Report Facts
Citations of noncompliance: 2
Hospice visits per week: 3
Hours delay in incontinence care: 5
Hours delay in incontinence care: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Provided information on Resident 1 and Resident 2's care needs and service plan deficiencies. |
| Associate Administrator B | Associate Administrator | Participated in interviews and record reviews related to Resident 1 and Resident 2. |
| Caregiver E | Caregiver | Provided care to Resident 1 and Resident 2 and gave interviews about care routines. |
| Caregiver F | Caregiver | Provided care to Resident 1 and gave interview about hospice services and care routines. |
| Caregiver G | Caregiver | Provided care to Resident 1 and Resident 2 and gave interviews about care routines. |
| Lead Caregiver H | Lead Caregiver | Observed providing care and interviewed regarding Resident 2's condition and care needs. |
| Hospice Caregiver J | Hospice Caregiver | Provided hospice care to Resident 1 including feeding and incontinence care. |
| Hospice Caregiver K | Hospice Caregiver | Provided hospice care to Resident 1 including feeding and incontinence care. |
| Facility Licensed Practical Nurse C | Licensed Practical Nurse | Participated in record reviews and interviews related to Resident 1 and Resident 2. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 19, 2024
Visit Reason
A complaint investigation was conducted on 02/19/2024 to determine if The Courtyard at Sussex CBRF was in substantial compliance with Wisconsin Statutes and Administrative Code requirements for community-based residential facilities.
Complaint Details
Complaint investigation concluded on 02/19/2024; the facility was found to have violations leading to issuance of Statement of Deficiency #8IPD11.
Findings
The Department issued a Statement of Deficiency (SOD #8IPD11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, establishing grounds for regulatory action and requiring the licensee to comply with all requirements within 45 days.
Report Facts
Appeal filing timeframe: 10
Compliance timeframe: 45
Posting duration: 90
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: 49
Deficiencies: 1
Date: Feb 19, 2024
Visit Reason
Surveyor conducted a complaint investigation at Courtyard at Sussex CBRF on 02/07/2024 following concerns about resident privacy and dignity.
Complaint Details
Complaint was substantiated. The investigation included interviews with Resident 1 and Nurse B, review of Resident Incident Report dated 12/04/2023, and documentation from Fire Chief and EMS personnel confirming the lift assist after the fall. Administrator A acknowledged the issue and committed to addressing it.
Findings
One deficiency was identified and the complaint was substantiated. Resident 1 was not treated with courtesy and full recognition of dignity by staff after a fall in the bathroom, where the resident was left exposed until EMS arrived for a lift assist.
Deficiencies (1)
Resident 1 was not treated with courtesy and full recognition of dignity by staff after a fall in the bathroom; resident was left exposed until EMS arrived.
Report Facts
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Nurse | Named in relation to the finding of not covering Resident 1 after fall |
| Administrator A | Administrator | Acknowledged the deficiency and committed to corrective action |
| Fire Chief C | Fire Chief | Provided documentation regarding EMS lift assist |
| Lieutenant D | Lieutenant | Responded to lift assist for Resident 1 |
| EMT E | EMT | Provided lift assist and covered Resident 1 |
Inspection Report
Routine
Census: 23
Deficiencies: 0
Date: Jan 18, 2023
Visit Reason
Surveyors conducted a standard survey at Courtyard at Sussex CBRF (The) on 01/18/2023.
Findings
No deficiencies were identified during the survey. A standard license will be issued.
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