Deficiencies (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
44 residents
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 12, 2025
Visit Reason
A Complaint Investigation was conducted on December 12, 2025, to determine if Willow Brooke Point Senior Living CBRF was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #WU9V11) 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.
Complaint Details
The visit was complaint-related, concluding a Complaint Investigation to assess compliance with applicable statutes and administrative codes. Specific substantiation status is not stated.
Report Facts
Days to achieve compliance: 45
Appeal filing period: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter as Bureau of Assisted Living, Division of Quality Assurance. |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Nov 12, 2025
Visit Reason
Surveyors conducted an investigation into two complaints at Willow Brooke Point Senior Living CBRF, one of which was substantiated.
Findings
Two deficiencies were identified related to inaccurate proof-of-use records for scheduled II drugs and improper documentation of medication administration, including a caregiver documenting medications not administered.
Complaint Details
One of two complaints was substantiated. Complaints involved concerns with proof-of-use records and medication administration causing negative resident outcomes.
Deficiencies (2)
| Description |
|---|
| The provider did not maintain accurate proof-of-use records for scheduled II drugs; discrepancies were found in medication counts and incomplete documentation. |
| The provider did not ensure the person administering medications recorded the name, dosage, date, and time of administration; a caregiver documented administration of medications not given. |
Report Facts
Medication count discrepancy: 1
Incomplete medication documentation: 1
Medications documented but not administered: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver A | Caregiver | Named in findings related to medication documentation errors and proof-of-use record discrepancies |
| Caregiver C | Caregiver | Observed medication carts and explained proof-of-use record process |
| Caregiver D | Caregiver | Participated in narcotic counts and acknowledged documentation issues |
| Caregiver E | Caregiver | Involved in narcotic counts and noted missed discrepancies |
| Administrator F | Former Administrator | Acknowledged for not double checking narcotic counts allowing problems to persist |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Apr 1, 2025
Visit Reason
An investigation into 3 complaints was conducted at Willow Brooke Point Senior Living CBRF on 04/01/2025 with information gathered through 04/02/2025.
Findings
All 3 complaints were unsubstantiated and no deficiencies were identified during the survey.
Complaint Details
Investigation of 3 complaints resulted in all complaints being unsubstantiated.
Report Facts
Complaints investigated: 3
Census: 44
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Aug 21, 2024
Visit Reason
Surveyor conducted four complaint investigations at Willow Brooke Point Senior Living CBRF.
Findings
All of the complaints were unsubstantiated.
Complaint Details
Four complaints were investigated and all were found to be unsubstantiated.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Mar 5, 2024
Visit Reason
An investigation into 4 complaints and a standard survey were conducted at Willow Brooke Point Senior Living CBRF on 03/04/2024 through 03/05/2024.
Findings
All complaints were unsubstantiated and there were no deficiencies identified with the survey process.
Complaint Details
Four complaints were investigated and all were found to be unsubstantiated.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Aug 31, 2023
Visit Reason
Surveyor conducted 3 complaint investigations and a verification visit at Willow Brooke Point Senior Living CBRF.
Findings
All previous deficiencies were corrected and no deficiencies were identified. Three complaints were unsubstantiated.
Complaint Details
Three (3) of 3 complaints: Unsubstantiated.
Report Facts
Revisit fee: 200
Census: 38
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 28, 2023
Visit Reason
A Verification Visit and Complaint Investigation were conducted to determine if Willow Brooke Point Senior Living CBRF was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD) #J0R14 for violations of state statutes and administrative codes, resulting in an Order to Comply with Requirements, Special Orders for staffing and care procedures, and a forfeiture totaling $4,590.00. The licensee must achieve and maintain substantial compliance within 45 days.
Complaint Details
The visit was complaint-related and included a verification visit to determine if violations in a prior Statement of Deficiency (SOD #J0R13) were corrected.
Deficiencies (2)
| Description |
|---|
| Violation of Wis. Admin. Code § DHS 83.36(1)(a) related to staffing requirements. |
| Violation of Wis. Stat. § 50.09(1)(L) related to ensuring each resident receives adequate and appropriate care. |
Report Facts
Forfeiture amount: 4590
Reduced forfeiture amount: 2983.5
Forfeiture breakdown: 240
Forfeiture breakdown: 900
Forfeiture breakdown: 750
Forfeiture breakdown: 1000
Forfeiture breakdown: 400
Forfeiture breakdown: 1300
Inspection fee: 200
Compliance timeframe: 45
Appeal timeframe: 10
Inspection Report
Re-Inspection
Census: 42
Capacity: 52
Deficiencies: 6
Feb 28, 2023
Visit Reason
A verification visit for Statement of Deficiency J07R13 and investigation into a self-report and 6 complaints was completed from 02/21/2023 through 02/28/2023 at Willow Brooke Point Senior Living CBRF.
Findings
Six deficiencies were identified including repeat deficiencies related to medication administration, failure to implement individual service plans, inadequate staffing, unsafe and unclean environment, and failure to provide adequate care resulting in pressure injuries. Three complaints were substantiated and three were unsubstantiated.
Complaint Details
Three complaints were substantiated and three were unsubstantiated related to medication administration, fall alarms, staffing shortages, and resident care.
Deficiencies (6)
| Description |
|---|
| Provider did not allow 2 of 2 residents reviewed to receive prescribed medications in the dosage and intervals ordered, including failure to remove fentanyl patch after 72 hours or discontinuation. |
| Provider did not ensure implementation and follow-through of individual service plans for 3 residents, including improper use of chair alarms and insufficient staff for transfers. |
| Provider did not review and revise individual service plans annually or upon changes for residents, including failure to update fall alarms and code status. |
| Provider did not have adequate staff to meet the needs of residents, resulting in long wait times, residents being left soiled, and insufficient assistance for transfers. |
| Provider failed to maintain a safe, clean, and comfortable environment; observed torn carpets, gouged drywall, dirty wheelchairs, and food debris in resident rooms. |
| Provider failed to ensure adequate and appropriate care to prevent and treat pressure injuries for a resident, resulting in worsening wounds, hospitalization, and hospice placement. |
Report Facts
Deficiencies identified: 6
Re-visit fee: 200
Facility licensed capacity: 52
Current census: 42
Staff scheduled: 3
Staff scheduled: 2
Resident falls: 8
Pressure injury wound measurements: 3.7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Former Shift Lead N | Shift Lead | Named in medication administration deficiency related to failure to remove fentanyl patch and re-education provided. |
| Caregiver A | Interviewed regarding improper implementation of chair alarms and transferring residents with hoyer lift alone. | |
| Caregiver J | Interviewed regarding training and practice of transferring residents with hoyer lift. | |
| Wellness Director F | Wellness Director | Interviewed regarding chair alarms, hoyer lift transfers, staffing, and resident care. |
| Administrator in Training I | Administrator in Training | Interviewed regarding staff training and staffing levels. |
| Family Member B | Interviewed regarding Resident 1's care and long wait times. | |
| Family Member C | Interviewed regarding Resident 2's care and call light response times. | |
| Family Member E | Interviewed regarding Resident 3's care and incidents of soiling and falls. | |
| Caregiver L | Interviewed regarding staffing shortages and call light wait times. | |
| Caregiver F | Interviewed regarding Resident 10's skin condition and care. | |
| Housekeeper K | Housekeeper | Interviewed regarding cleaning practices and wheelchair cleanliness. |
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