Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
19 residents
Based on a June 2025 inspection.
Occupancy over time
Notice
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
A standard survey was conducted on June 10, 2025, to determine if The Legacy of Deforest 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 Statement of Deficiency #2YBI14 and imposed a total forfeiture of $1900.00. A $200 inspection fee for a verification visit was also assessed.
Report Facts
Forfeiture amount: 1900
Forfeiture amount (reduced): 1235
Forfeiture amount: 400
Forfeiture amount: 1500
Inspection fee: 200
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: 19
Deficiencies: 3
Date: Jun 10, 2025
Visit Reason
Surveyor conducted a standard licensing survey, verification visit, and complaint investigation at Legacy of DeForest, a CBRF located in DeForest, WI.
Complaint Details
The complaint was substantiated. The investigation found violations including missing caregiver background check and inadequate training, as well as failure to monitor a resident's oxygen levels as required.
Findings
Three violations of Chapter DHS 83 were issued, including a repeat violation. The complaint was substantiated. Deficiencies included failure to conduct a caregiver background check, lack of documented training for a caregiver in personal cares and dietary, and failure to monitor a resident's oxygen levels as directed in the Individual Service Plan.
Deficiencies (3)
Failure to conduct and document a caregiver background check for Caregiver L at the time of hire.
Failure to ensure Caregiver L was trained in personal cares and dietary duties prior to performing these tasks.
Failure to monitor Resident 3's oxygen levels each shift as directed by the Individual Service Plan, with no documentation confirming monitoring.
Report Facts
Violations issued: 3
Dates of oxygen level checks: 06/01/2025 at 2:29 PM 85%, 06/01/2025 at 5:25 PM 93%, 06/04/2025 at 7:11 AM 93%
Date hired: Caregiver L hired on 03/21/2025
Resident admission date: Resident 3 admitted 07/17/2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Interviewed regarding caregiver background check, training, and resident oxygen monitoring deficiencies. | |
| Caregiver L | Subject of deficiencies related to missing background check and lack of documented training. |
Inspection Report
Enforcement
Deficiencies: 2
Date: Oct 11, 2024
Visit Reason
A verification visit was conducted on 10/11/2024 to determine if The Legacy of Deforest was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities (CBRF).
Findings
The Department issued a Statement of Deficiency (SOD #2YBI13) 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 $1,540. The licensee was ordered to comply with requirements, develop written procedures, provide staff training, and notify legal representatives of certain residents.
Deficiencies (2)
Violation of Wis. Admin. Code 83.14(2)(a)
Violation of Wis. Admin. Code 83.38(1)(g)
Report Facts
Forfeiture amount: 1540
Forfeiture amount: 500
Forfeiture amount: 1040
Reduced forfeiture amount: 1001
Inspection fee: 200
Compliance timeframe: 45
Notification timeframe: 7
Extension request timeframe: 10
Posting duration: 90
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: 22
Capacity: 25
Deficiencies: 2
Date: Oct 11, 2024
Visit Reason
Surveyor conducted a verification visit at The Legacy of Deforest to assess compliance with previous requirements and special orders outlined in a Notice and Order letter from the Department.
Findings
Two deficiencies were identified, including one repeat violation related to health monitoring and failure to ensure compliance with laws governing the Community-Based Residential Facility (CBRF). The provider did not ensure changes in residents' health were communicated to nursing staff and failed to monitor oxygen and blood sugar levels adequately.
Deficiencies (2)
Licensee did not ensure the facility and its operation complied with all laws governing the Community-Based Residential Facility (CBRF), including failure to comply with requirements and special orders outlined in a Notice and Order letter.
Failure to ensure changes in 2 of 2 residents' health were communicated to nursing staff when a change of condition occurred, including inadequate monitoring of oxygen levels and blood sugar levels.
Report Facts
Revisit fee: 200
Deficiencies identified: 2
Licensed capacity: 25
Resident census: 22
Blood sugar readings: 327
Blood sugar readings: 355
Blood sugar readings: 311
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director A | Executive Director | Interviewed regarding health monitoring and documentation deficiencies |
| Registered Nurse H | Registered Nurse | Interviewed regarding health monitoring and documentation deficiencies |
| Healthcare Coordinator B | Healthcare Coordinator | Interviewed regarding blood sugar monitoring and documentation |
| Resident Assistant I | Resident Assistant | Interviewed regarding blood sugar reporting procedures |
| Resident Assistant J | Resident Assistant | Interviewed regarding blood sugar reporting procedures |
| Resident Assistant K | Resident Assistant | Interviewed regarding blood sugar reporting procedures |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 2
Date: Jun 5, 2024
Visit Reason
Surveyor conducted a verification visit and a complaint investigation at The Legacy of Deforest following information gathered between 05/29/2024 and 06/05/2024. The visit was triggered by a complaint alleging failure to notify a resident's representative after an unwitnessed fall.
Complaint Details
Complaint was substantiated. The provider did not immediately notify 1 of 1 resident's representative after an unwitnessed fall causing fractures. Also, the provider failed to communicate changes in resident's health status related to black bowel movements after hospitalization.
Findings
Two deficiencies were identified related to failure to immediately notify a resident's legal representative and physician after an incident, and failure to communicate changes in a resident's health status, including black bowel movements. The complaint was substantiated and a $200 revisit fee is being assessed.
Deficiencies (2)
Failure to immediately notify resident's legal representative and physician of an incident or injury, specifically an unwitnessed fall resulting in fractured ribs, clavicle, and hip.
Failure to ensure changes in resident's health status, including black bowel movements indicating possible internal bleeding, were communicated to nursing staff.
Report Facts
Revisit fee: 200
Census: 21
Deficiencies identified: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chief Operating Officer N | Chief Operating Officer | Interviewed regarding follow-up and communication failures |
| Vice President of Healthcare K | Vice President of Healthcare | Responded to concerns about notification failures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 5, 2024
Visit Reason
A complaint investigation and verification visit was conducted to determine if The Legacy of DeForest was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, conducted on 06/05/2024 to investigate allegations and verify compliance. The Department found violations and issued enforcement actions including a forfeiture and special orders.
Findings
The Department issued a Statement of Deficiency (SOD #2YBI12) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements to protect resident health, safety, and rights, including developing corrective procedures and providing staff training. A forfeiture of $780 was imposed for the violations, with a reduced option of $507 if not appealed. An inspection fee of $200 was also assessed for a verification visit.
Deficiencies (1)
Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #2YBI12
Report Facts
Forfeiture amount: 780
Reduced forfeiture amount: 507
Inspection fee: 200
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
Deficiencies: 0
Date: Feb 12, 2024
Visit Reason
A complaint investigation was conducted to determine if The Legacy of Deforest 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 02/12/2024. The Department found violations substantiating the complaint and issued enforcement actions including a Statement of Deficiency and forfeiture.
Findings
The Department issued a Statement of Deficiency (SOD #2YBI11) identifying violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements and implement corrective measures related to fall management and use of assistive devices. A forfeiture of $700 was imposed for the violations.
Report Facts
Forfeiture amount: 700
Reduced forfeiture amount: 455
Forfeiture amount: 300
Forfeiture amount: 400
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: 21
Capacity: 25
Deficiencies: 2
Date: Feb 12, 2024
Visit Reason
Surveyor conducted a complaint investigation at The Legacy of DeForest on 02/05/2024 with information gathered through 02/12/2024. The investigation was triggered by concerns regarding fall risk monitoring and resident treatment adequacy.
Complaint Details
Complaint was substantiated. The investigation found that residents who were fall risks were not monitored properly, and the provider failed to ensure adequate treatment and fall risk interventions for Resident 1.
Findings
Two deficiencies were identified, including a repeat violation related to inadequate treatment and fall risk interventions for Resident 1. The provider failed to ensure adequate treatment and proper monitoring of fall risks, with multiple unwitnessed falls documented and bed/chair alarm malfunctions noted.
Deficiencies (2)
Provider did not ensure 1 of 1 resident received adequate treatment; Resident 1's fall risk intervention was not utilized to ensure safety.
Provider did not ensure an assessment of Resident 1's physical and mental condition was completed when there was a change in needs; Resident 1 sustained 6 falls between 10/17/2023 and 02/07/2024 and a fall assessment was not completed. Resident 1 utilized bed rails and an assessment had not been completed. This is a repeat deficiency.
Report Facts
Deficiencies identified: 2
Falls sustained: 6
Licensed capacity: 25
Census: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver B | Interviewed and observed during investigation; reported bed alarm malfunction and fall incidents. | |
| Caregiver D | Interviewed during investigation; reported observations of Resident 1's falls. | |
| Executive Director A | Executive Director | Interviewed; stated no system was in place to check bed/chair alarm status during shift changes and was unable to locate bed rail assessments. |
| Family Member F | Interviewed; expressed concern about Resident 1's multiple falls and lack of explanation. | |
| Caregiver E | Prepared incident reports documenting Resident 1's falls. | |
| Lead Caregiver C | Prepared incident reports documenting Resident 1's falls. |
Inspection Report
Follow-Up
Census: 22
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
Surveyor conducted a verification visit at The Legacy of DeForest to verify compliance and correction of previous deficiencies.
Findings
No deficiencies were identified during the verification visit. A $200 revisit fee is being assessed under statutory provisions.
Report Facts
Revisit fee: 200
Inspection Report
Routine
Deficiencies: 2
Date: Jun 16, 2023
Visit Reason
A standard survey and verification visit was conducted on June 16, 2023, to determine if Legacy of Deforest was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #085D12) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A total forfeiture of $1100 was imposed for these violations, with some forfeitures accruing daily until compliance is achieved and verified.
Deficiencies (2)
Violation of Wis. Admin. Code 83.35(3)(d)
Violation of Wis. Admin. Code 83.37(1)(i)
Report Facts
Forfeiture amount: 1100
Reduced forfeiture amount: 715
Forfeiture amount for violation 83.35(3)(d): 900
Forfeiture amount for violation 83.37(1)(i): 200
Inspection fee: 200
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
Annual Inspection
Census: 20
Capacity: 25
Deficiencies: 4
Date: Jun 7, 2023
Visit Reason
A standard licensure survey and verification visit was conducted to assess compliance with regulatory requirements and verify correction of previous deficiencies.
Findings
Four deficiencies were identified, including failure to update 5 out of 6 Individual Service Plans (ISPs) annually or with changes, lack of documentation for PRN psychotropic medication rationale and behaviors, failure to conduct required quarterly fire drills with residents and staff in 2022, and failure to conduct semi-annual other evacuation drills in 2020 and 2021.
Deficiencies (4)
Provider did not ensure 5 out of 6 Individual Service Plans (ISP) reviewed were updated annually or when there was a change in condition.
Provider did not ensure that Resident 9's prescribed PRN psychotropic medications were documented on the ISP with rationale for use and detailed description of behaviors indicating need for administration.
Provider did not conduct quarterly fire drills (including at least one simulating usual sleeping hours) with both employees and residents in 2022.
Provider did not ensure evacuation drills such as tornado, flooding, or other emergency or disaster were conducted at least semi-annually in 2020 and 2021.
Report Facts
Deficiencies identified: 4
Revisit fee: 200
Census: 20
Total licensed capacity: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chief Operating Officer M | Chief Operating Officer | Discussed observations and plans to update ISPs and PRN medication documentation during exit interview. |
| Health Care Coordinator Q | Health Care Coordinator | Collaborated with COO M to update ISPs and PRN medication documentation. |
| Resident Assistant F | Resident Assistant | Observed assisting Resident 7 during meal and interviewed about fire and evacuation drills. |
| Resident Assistant U | Resident Assistant | Interviewed about participation in fire and evacuation drills. |
| Resident Assistant V | Resident Assistant | Interviewed about participation in fire and evacuation drills and emergency procedures. |
Viewing
Loading inspection reports...
