Inspection Reports for Willowick

2860 LIBERTY LANE, JANESVILLE, WI, 53545

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 1 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

78% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/year

Deficiencies per year

4 3 2 1 0
2023
2024
2025

Census

Latest occupancy rate 17 residents

Based on a September 2025 inspection.

This facility has shown a decline in demand based on occupancy rates.

Census over time

8 12 16 20 24 May 2023 Dec 2023 Apr 2024 Aug 2025 Sep 2025

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Sep 24, 2025

Visit Reason
Two complaint investigations were concluded for Willowick to determine if the facility was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.

Complaint Details
Two complaint investigations were concluded on 09/24/2025, resulting in findings of violations and issuance of SOD #JCO211.
Findings
The Department issued a Statement of Deficiency (SOD #JCO211) for violations of Wisconsin Statutes and Administrative Code provisions related to the operation of the facility, resulting in an imposed forfeiture of $500.

Report Facts
Forfeiture amount: 500 Reduced forfeiture amount: 325 Forfeiture payment timeframe: 10 Compliance timeframe: 45 Inspection fee: 200

Employees mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter.
Hillary HolmanAssisted Living Regional DirectorContact person for questions about the letter.

Inspection Report

Complaint Investigation
Census: 17 Deficiencies: 1 Date: Sep 24, 2025

Visit Reason
On 09/23/2025, the bureau of assisted living southern regional office conducted 2 complaint investigations at Willowick, a CBRF located in Beloit, WI.

Complaint Details
Two complaint investigations were conducted. One complaint was substantiated and one was unsubstantiated. The substantiated complaint involved failure to update Resident 1's individualized service plan after changes in condition and care needs.
Findings
As a result of the survey, 1 violation of DHS Chapter 83 was identified. One complaint was substantiated and one complaint was unsubstantiated. The provider failed to ensure Resident 1's individualized service plan (ISP) was reviewed and updated when there was a change in the resident's needs, abilities, or physical or mental condition.

Deficiencies (1)
83.35(3)(d) Service plans updated annually or on changes - Provider did not ensure Resident 1's individualized service plan was reviewed when there was a change in the resident's needs, abilities or physical or mental condition.
Report Facts
Census: 17 Medication administration days: 7 Medication administration dates: 7

Employees mentioned
NameTitleContext
Administrator AAdministratorAcknowledged Resident 1's diagnosis, antibiotic prescription, fall with injury, and plan for family to apply ACE bandage
Licensee BLicenseeAcknowledged Resident 1's diagnosis, antibiotic prescription, fall with injury, and plan for family to apply ACE bandage
Practical Nurse CPractical NurseDocumented Resident 1's fall, medication administration, and care instructions; acknowledged diagnosis and care plans

Inspection Report

Routine
Deficiencies: 0 Date: Aug 27, 2025

Visit Reason
A standard survey was conducted on August 27, 2025, by the Division of Quality Assurance, Bureau of Assisted Living, to determine if Willowick was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.

Findings
The Department issued a Statement of Deficiency (SOD #J8LR11) 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
Days to achieve compliance: 45 Appeal filing deadline: 10 Posting duration: 90

Employees mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the notice letter as Bureau of Assisted Living, Division of Quality Assurance.
Hillary HolmanAssisted Living Regional DirectorContact person for questions about the letter.

Inspection Report

Routine
Census: 15 Deficiencies: 1 Date: Aug 27, 2025

Visit Reason
A standard survey was conducted at Willowick, a CBRF in Beloit, to assess compliance with regulatory requirements.

Findings
One deficiency was identified related to the failure to include the rationale for use and description of behaviors indicating the need for administration of PRN psychotropic medication in the Individual Service Plan (ISP) for one resident receiving Lorazepam .5 mg as needed.

Deficiencies (1)
The provider did not include the rationale for use and description of behaviors which indicate the need for administration of Lorazepam .5 mg in the Individual Service Plan of one resident receiving psychotropic medications as needed.
Report Facts
Census: 15

Employees mentioned
NameTitleContext
Nurse Manager AConfirmed that the rationale for use and behavior description for Lorazepam .5 mg was not documented in the ISP.
Executive Director BStated that Lorazepam will be added to the ISP.

Inspection Report

Complaint Investigation
Census: 16 Deficiencies: 0 Date: Apr 9, 2024

Visit Reason
Surveyor conducted a complaint investigation at Willowick on 04/09/2024.

Complaint Details
The complaint was unsubstantiated.
Findings
No deficiencies were identified during the complaint investigation. The complaint was unsubstantiated.

Inspection Report

Complaint Investigation
Census: 17 Deficiencies: 0 Date: Dec 20, 2023

Visit Reason
Surveyor conducted a complaint investigation at Willowick on 12/20/2023.

Complaint Details
The complaint was unsubstantiated.
Findings
No deficiencies were identified during the complaint investigation. The complaint was unsubstantiated.

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: May 4, 2023

Visit Reason
A standard survey and complaint investigation was conducted to determine if Willowick Assisted Living Beloit II LLC was in substantial compliance with Wisconsin Statutes Chapter 50 and Wisconsin Administrative Code Chapter DHS 83, which govern the administration and operation of community-based residential facilities.

Complaint Details
The visit was complaint-related as it included a complaint investigation; however, the substantiation status is not stated.
Findings
The Department issued a Statement of Deficiency (SOD #8V5811) for violations of the applicable statutes and administrative codes, establishing grounds for regulatory action and an order to comply with requirements to protect resident health, safety, and welfare.

Report Facts
Appeal time frame: 10 Compliance time frame: 45 Posting duration: 90

Employees mentioned
NameTitleContext
Kathleen D. LyonsInterim Assisted Living DirectorSigned the notice letter.
Hillary HolmanAssisted Living Regional DirectorContact person for questions about the letter.

Inspection Report

Complaint Investigation
Census: 19 Deficiencies: 1 Date: May 3, 2023

Visit Reason
Surveyors conducted a complaint investigation and standard survey at Willowick on 05/04/2023. The complaint was unsubstantiated.

Complaint Details
The complaint was unsubstantiated.
Findings
One deficiency was identified related to the improper disposition of medications. The provider did not ensure that 4 of 4 resident medications were disposed of after 30 days of the expiration date, with expired medications stored alongside current medications for Residents 4, 5, 6, and 7.

Deficiencies (1)
Provider did not ensure 4 of 4 resident medications were disposed of after 30 days of the expiration date; expired medications were stored alongside current medications.
Report Facts
Expired medications: 8 Census: 19

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