Inspection Reports for The Suites at Beloit
2122 PIONEER DRIVE, BELOIT, WI, 53511
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
4
3
2
1
0
Census
Latest occupancy rate
43 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 43
Deficiencies: 0
Date: Aug 14, 2025
Visit Reason
The surveyor conducted two verification visits to assess the correction of deficiencies from previous statements of deficiency dated 04/03/2025 and 01/29/2025 at Suites At Beloit, a CBRF in Beloit.
Findings
No new violations of Chapter DHS 83 were issued during this survey. Two deficiencies from the previous statement dated 04/03/2025 and one violation from the statement dated 01/29/2025 were substantially corrected.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
A complaint investigation was conducted on April 3, 2025, to determine if Suites at Beloit was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, concluding a complaint investigation on April 3, 2025, with violations substantiated as per the Statement of Deficiency #TWL811.
Findings
The Department issued a Statement of Deficiency (SOD #TWL811) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation and an imposed forfeiture of $750.00 for the identified violations.
Report Facts
Forfeiture amount: 750
Reduced forfeiture amount: 487.5
Forfeiture amount: 300
Forfeiture amount: 450
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: 40
Deficiencies: 2
Date: Apr 2, 2025
Visit Reason
Surveyors conducted a complaint investigation at Suites At Beloit, a CBRF located in Beloit, WI, from 04/02/2025 through 04/03/2025.
Complaint Details
The complaint was unsubstantiated.
Findings
Two deficiencies were identified, both repeat violations: failure to update an individual service plan (ISP) to address elopement and failure to document units of medication administered for one resident. The complaint was unsubstantiated.
Deficiencies (2)
Provider did not ensure an individual service plan (ISP) was updated when there was a change in condition or need, specifically to address elopement from the facility.
Provider did not ensure that one of two resident's units of medication was documented after administration, specifically for sliding scale Novolog Insulin.
Report Facts
Deficiencies identified: 2
Medication administrations undocumented: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Interviewed regarding Resident 1's elopement and ISP updates, and acknowledged documentation issues with Resident 2's medication administration. | |
| Nurse Manager B | Interviewed and agreed that medication units should be documented on the MAR. |
Notice
Deficiencies: 0
Date: Jan 29, 2025
Visit Reason
A verification visit and complaint investigation was conducted on January 29, 2025, to determine if Suites at Beloit was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related and included a verification visit to determine compliance. 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 Statement of Deficiency #4V2G12 and imposed a forfeiture of $1000.00. The licensee is ordered to comply immediately and maintain compliance within 45 days.
Report Facts
Forfeiture amount: 1000
Reduced forfeiture amount: 650
Inspection fee: 200
Days to achieve compliance: 45
Days to request extension: 10
Days to pay forfeiture: 10
Days to pay inspection fee: 10
Days to file appeal: 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: 37
Deficiencies: 1
Date: Jan 29, 2025
Visit Reason
The Bureau of Assisted Living conducted a verification visit and complaint investigation at Suites at Beloit, a CBRF located in Beloit, WI.
Complaint Details
Complaint was unsubstantiated.
Findings
One deficiency related to continuing education requirements was issued as a repeat deficiency. The complaint was unsubstantiated, and a $200 revisit fee was assessed.
Deficiencies (1)
The provider did not ensure resident care staff received at least 15 hours per calendar year of continuing education including required topics such as fire safety and medications.
Report Facts
Revisit fee: 200
Census: 37
Continuing education hours: 12.25
Continuing education hours: 12.25
Continuing education hours: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver E | Named in continuing education deficiency; hired 02/02/2022 | |
| Caregiver G | Named in continuing education deficiency; hired 11/01/2021 | |
| Caregiver H | Named in continuing education deficiency; hired 02/17/2021 | |
| Administrator A | Administrator | Acknowledged continuing education deficiencies and documented plan for 2025 |
Notice
Deficiencies: 0
Date: Oct 2, 2024
Visit Reason
A standard survey and complaint investigation was conducted to determine if The Suites at Beloit was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit included a complaint investigation as part of the standard survey concluded on 10/02/2024.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency #4V2G11 and an imposed forfeiture of $600.00 for noncompliance.
Report Facts
Forfeiture amount: 600
Reduced forfeiture amount: 390
Forfeiture payment timeframe: 10
Compliance timeframe: 45
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
Complaint Investigation
Census: 40
Capacity: 54
Deficiencies: 3
Date: Oct 1, 2024
Visit Reason
On 10/01/2024, the Bureau of Assisted Living, Southern Regional Office, conducted a standard survey and a complaint investigation at The Suites of Beloit, a CBRF located in Beloit, WI.
Complaint Details
Complaint was unsubstantiated.
Findings
The survey resulted in 3 violations of DHS Chapter 83. The complaint was unsubstantiated. Deficiencies included failure to ensure resident care staff received at least 15 hours per calendar year of continuing education relevant to job responsibilities, failure to maintain heating system properly with required maintenance, and failure to ensure interconnected smoke detection and heat detection systems were functional and maintained.
Deficiencies (3)
The provider did not ensure resident care staff received at least 15 hours per calendar year of continuing education beginning with the first full calendar year of employment, including training on standard precautions, client group related training, medications, resident rights, prevention and reporting of abuse, neglect and misappropriation, and fire safety/emergency procedures including first aid.
The provider did not ensure that a heating contractor or local utility company completed maintenance on the gas furnace system at least once every 3 years.
The provider did not ensure the interconnected smoke detection system and interconnected heat detection system to protect the entire facility were functional; smoke detectors failed testing and had not been repaired or retested since 03/28/2024.
Report Facts
Violations issued: 3
Continuing education hours required: 15
Continuing education hours documented for Caregiver D in 2023: 5.25
Continuing education hours documented for Caregiver E in 2023: 3.75
Continuing education hours documented for Caregiver F in 2023: 1.75
Facility maximum capacity: 54
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Acknowledged deficiencies in staff training and heating system maintenance |
| Caregiver D | Named in continuing education deficiency; hired 12/14/2021; had 5.25 hours continuing education in 2023 | |
| Caregiver E | Named in continuing education deficiency; hired 02/02/2022; had 3.75 hours continuing education in 2023 | |
| Caregiver F | Named in continuing education deficiency; hired 02/23/2022; had 1.75 hours continuing education in 2023 | |
| Maintenance Manager C | Maintenance Manager | Acknowledged smoke detectors had not been repaired or retested since 03/28/2024 |
Inspection Report
Follow-Up
Census: 38
Deficiencies: 0
Date: Jan 8, 2024
Visit Reason
The surveyor conducted two verification visits to The Suites At Beloit to verify correction of previous deficiencies.
Findings
No deficiencies were identified during the visit. All previous violations from statements of deficiency dated 08/23/2023 and 05/10/2023 were substantially corrected.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Date: Nov 3, 2023
Visit Reason
The Bureau of Assisted Living, Southern Regional Office conducted 2 complaint investigations at The Suites At Beloit, a CBRF located in Beloit, WI.
Complaint Details
Two complaints were investigated; one complaint was substantiated and one complaint was unsubstantiated.
Findings
As a result of the investigation, 0 violations of Chapter DHS 83 were issued. One complaint was substantiated and one complaint was unsubstantiated.
Report Facts
Complaints investigated: 2
Complaints substantiated: 1
Complaints unsubstantiated: 1
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 23, 2023
Visit Reason
A complaint investigation and verification visit was conducted to determine if Suites at Beloit 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 following a complaint investigation. The Department determined violations and issued enforcement actions.
Findings
The Department issued a Statement of Deficiency #7BFM12 for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements, implement corrective measures, and provide staff training. A forfeiture of $300 was imposed, with a reduced payment option of $195. Additionally, a $200 inspection fee was assessed for a revisit to verify correction of prior deficiencies.
Deficiencies (1)
Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in Statement of Deficiency #7BFM12
Report Facts
Forfeiture amount: 300
Reduced forfeiture amount: 195
Revisit 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
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Aug 23, 2023
Visit Reason
Surveyor conducted a verification visit and complaint investigation at The Suites At Beloit following a complaint.
Complaint Details
The complaint was substantiated. A $200 revisit fee is being assessed under Wis. Stat. Ch. 50.
Findings
One deficiency was identified related to rooms not being clean and free from odors, specifically strong urine odors and dried bowel movement on toilet risers in multiple resident bathrooms. The complaint was substantiated and the deficiency was a repeat violation.
Deficiencies (1)
Provider did not ensure that all rooms were clean and free from odor, with strong urine odors and dried bowel movement observed in resident bathrooms.
Report Facts
Revisit fee: 200
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed and confirmed odor issues, stated increased cleaning rounds | |
| Nurse Manager Assistant | Interviewed during survey |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 10, 2023
Visit Reason
A complaint investigation was conducted on May 10, 2023, to determine if Suites at Beloit was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The complaint investigation concluded that the facility was not in substantial compliance with applicable statutes and administrative codes, leading to issuance of a Statement of Deficiency and enforcement actions including a 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 #X1V311) and imposed a forfeiture of $300.00. The licensee was ordered to comply with all requirements within 45 days and was informed of possible inspection fees and appeal rights.
Report Facts
Forfeiture amount: 300
Reduced forfeiture amount: 195
Compliance timeframe: 45
Payment timeframe: 10
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
Complaint Investigation
Census: 20
Deficiencies: 2
Date: May 10, 2023
Visit Reason
Surveyor conducted a complaint investigation at Suites at Beloit (The) on 05/10/2023 following a complaint received on 03/28/2023 alleging concerns with Resident 1's Oxycodone running out.
Complaint Details
The complaint was substantiated. It involved concerns about Resident 1's Oxycodone running out and missing proof-of-use records. The deficiency related to medication administration documentation was cited for the fourth time.
Findings
Two deficiencies were identified, including a repeat violation. The provider failed to maintain accurate proof-of-use records for Resident 1's Oxycodone medication for January 2023 and from 02/20/2023 to 03/22/2023, and did not ensure accurate documentation of medication administration on the Medication Administration Record (MAR).
Deficiencies (2)
Provider did not ensure Resident 1's proof-of-use record included required details such as resident's name, practitioner's name, dose, signature of administering person, and remaining drug balance for January 2023 and from 02/20/2023-03/22/2023.
Provider did not ensure administration of Resident 1's Oxycodone narcotic medication was accurately recorded on the MAR, with multiple dates missing initials.
Report Facts
Census: 20
Medication administration missing initials count: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Provided Resident 1's proof-of-use record and acknowledged staff forget to initial MAR at times | |
| Caregiver B | Reviewed provider's policy on proof-of-use record and described documentation process | |
| Nurse Manager Assistant C | Reviewed proof-of-use records weekly, coordinated pharmacy deliveries, and searched for missing documentation |
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