Inspection Reports for Waterford Place
808 CORNERSTONE CROSSING, WATERFORD, WI, 53185
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
48 residents
Based on a October 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 2, 2025
Visit Reason
A verification visit and two complaint investigations were conducted on October 2, 2025, to determine if Waterford Place was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued Statement of Deficiency (SOD) #INCB13 for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a $400 forfeiture and an imposed $200 inspection fee for a revisit to verify correction of prior violations.
Complaint Details
Two complaint investigations were concluded along with a verification visit to assess compliance with statutory and administrative requirements.
Deficiencies (1)
| Description |
|---|
| Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #INCB13 |
Report Facts
Forfeiture amount: 400
Reduced forfeiture amount: 260
Revisit 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 |
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Oct 2, 2025
Visit Reason
The surveyor conducted a verification visit and two complaint investigations at Waterford Place on 10/02/2025.
Findings
One deficiency was identified related to dietary training for employees performing dietary duties. Two complaints were unsubstantiated. A $200 revisit fee is being assessed under statutory provisions.
Complaint Details
Two complaints were investigated and found to be unsubstantiated.
Deficiencies (1)
| Description |
|---|
| The provider did not ensure 2 of 2 employees (Dining Director H and Cook I) obtained dietary training prior to or within 90 days after assuming dietary duties. |
Report Facts
Revisit fee: 200
Number of deficiencies identified: 1
Number of complaints investigated: 2
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dining Director H | Named in deficiency for not having dietary training. | |
| Cook I | Named in deficiency for not having dietary training. | |
| Associate Administrator G | Interviewed regarding dietary training for kitchen staff. |
Inspection Report
Enforcement
Deficiencies: 0
Apr 28, 2025
Visit Reason
A verification visit, standard survey, and two complaint investigations were conducted to determine if Waterford Place 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 at Waterford Place, resulting in a Statement of Deficiency (SOD #INCB12) and imposition of a total forfeiture of $1,100.00. A $200 inspection fee for a revisit was also assessed to verify correction of prior violations.
Complaint Details
Two complaint investigations were part of the visit concluded on April 28, 2025, but substantiation status is not stated.
Report Facts
Forfeiture amount: 1100
Reduced forfeiture amount: 715
Forfeiture amount: 200
Forfeiture amount: 300
Forfeiture amount: 200
Forfeiture amount: 400
Inspection fee: 200
Compliance timeframe: 45
Appeal timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter |
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
Inspection Report
Routine
Census: 50
Deficiencies: 6
Apr 28, 2025
Visit Reason
Surveyor conducted a verification visit, standard survey, and two complaint investigations at Waterford Place, a Community-Based Residential Facility (CBRF) in Waterford, WI.
Findings
Six deficiencies were identified, including one repeat deficiency. Two complaints were unsubstantiated. Deficiencies included lack of required continuing education for staff, failure to screen residents for communicable diseases including tuberculosis, failure to update individual service plans for residents with wounds, lack of heating system maintenance documentation, incomplete fire drill records, and missing annual fire detection system inspection.
Complaint Details
Two complaints were investigated and both were unsubstantiated.
Deficiencies (6)
| Description |
|---|
| Provider did not ensure 1 of 1 staff received at least 15 hours per calendar year of continuing education in 2024. |
| Provider did not ensure 2 of 2 residents reviewed were screened for clinically apparent communicable disease, including tuberculosis, within 90 days before or 7 days after admission. |
| Provider did not update the Individual Service Plan when 1 of 1 resident had a pressure ulcer and wound care. This is a repeat deficiency. |
| Provider could not provide documentation to show that the heating system has been maintained in a safe and properly functioning condition for 1 of 1 furnace. |
| Provider did not ensure fire drills were conducted quarterly and at least one drill simulated conditions during usual sleeping hours for 1 of 1 year reviewed (2024). |
| Provider did not ensure the fire detection system was inspected for 1 of 1 calendar year (2024). |
Report Facts
Deficiencies identified: 6
Repeat deficiencies: 1
Revisit fee: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver F | Named in deficiency for not having 15 hours of continuing education in 2024. | |
| Administrator E | Interviewed regarding continuing education, fire drills, furnace inspection, and fire detection system inspection. | |
| Regional Wellness Director D | Interviewed regarding resident health screenings and individual service plan updates. |
Notice
Deficiencies: 0
Sep 19, 2024
Visit Reason
A three complaint investigation was conducted to determine if Waterford Place 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 #INCB11 and an imposed order to comply with requirements to protect resident health, safety, and welfare.
Complaint Details
The visit was a complaint investigation involving three complaints. Specific substantiation status is not stated.
Report Facts
Compliance timeframe: 45
Inspection fee: 200
Appeal timeframe: 10
Posting duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter. |
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 57
Deficiencies: 2
Sep 11, 2024
Visit Reason
Surveyors conducted three complaint investigations at Waterford Place, a Community-Based Residential Facility, to investigate concerns related to incident reporting and service plan updates for Resident 1.
Findings
Two deficiencies were identified: the provider failed to submit a required written report within 3 working days after a serious injury incident involving Resident 1, and the provider did not update Resident 1's Individual Service Plan after a change in mobility/transfer status.
Complaint Details
Three of three complaints were unsubstantiated. The investigation focused on Resident 1's fall incident and related care plan updates.
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to submit a written report to the department within 3 working days after an incident resulting in serious injury requiring emergency room treatment for Resident 1. | A CBRF shall send a written report to the department within 3 working days after any incident or accident resulting in serious injury requiring hospital admission or emergency room treatment. |
| Failure to update the Individual Service Plan when Resident 1's mobility/transfer status changed. | — |
Report Facts
Census: 42
Total Capacity: 57
Complaints investigated: 3
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Jun 6, 2024
Visit Reason
Surveyors conducted two complaint investigations at Waterford Place, a Community-Based Residential Facility (CBRF) in Waterford, WI.
Findings
No deficiencies were identified during the investigations. Both complaints were found to be unsubstantiated.
Complaint Details
Two complaints were investigated and both were unsubstantiated.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Mar 7, 2024
Visit Reason
Surveyors conducted two complaint investigations at Waterford Place.
Findings
No deficiencies were identified. Two of two complaints were unsubstantiated.
Complaint Details
Two complaints were investigated and both were found to be unsubstantiated.
Inspection Report
Routine
Census: 40
Deficiencies: 0
Sep 26, 2023
Visit Reason
Surveyors completed a standard and complaint survey at Waterford Place.
Findings
No deficiencies were identified. One of one complaint was unsubstantiated.
Complaint Details
One of 1 complaint was unsubstantiated.
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