Inspection Reports for New Perspective Sun Prairie

222 S Bristol St, Sun Prairie, WI 53590, United States, WI, 53590

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 15 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

226% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/year

Deficiencies per year

12 9 6 3 0
2023
2024
2025

Census

Latest occupancy rate 32 residents

Based on a August 2025 inspection.

Census over time

24 32 40 48 56 Sep 2023 May 2024 Nov 2024 Jan 2025 Aug 2025

Inspection Report

Routine
Census: 32 Deficiencies: 0 Date: Aug 5, 2025

Visit Reason
The bureau of assisted living southern regional office conducted 2 verification visits at New Perspective, a CBRF located in Sun Prairie, WI.

Findings
As a result of this survey, 0 violations of DHS Chapter 83 were issued. Two violations from previous statements of deficiency dated 04/30/2025 and 01/29/2025 were corrected.

Report Facts
Revisit fee: 200

Inspection Report

Complaint Investigation
Census: 32 Capacity: 50 Deficiencies: 1 Date: Apr 30, 2025

Visit Reason
The bureau of assisted living southern regional office conducted 2 complaint investigations and a verification visit at New Perspective Sun Prairie, a CBRF located in Sun Prairie, WI, triggered by a complaint regarding abuse and behavior management concerns.

Complaint Details
One complaint was substantiated. The complaint involved Resident 2 slapping Resident 1 aggressively multiple times, causing safety concerns. Staff failed to initiate timely interventions to protect Resident 1. The facility did not update Resident 1's fall management plan despite multiple witnessed falls. APS was involved and an APS report was filed.
Findings
Two violations of DHS Chapter 83 were issued related to failure to prevent conditions of substantial risk, including Resident 2's aggressive behaviors toward Resident 1, lack of timely interventions, and inadequate fall management. The facility failed to ensure Resident 1's safety while cohabitating with Resident 2, who exhibited aggressive behaviors.

Deficiencies (1)
Not permit a condition of substantial risk by allowing the existence or continuation of a condition which is or may create a substantial risk to the health, safety or welfare of any resident.
Report Facts
Violations issued: 2 Revisit fee: 200 Resident falls: 7 Internal stitches: 8 External stitches: 10

Employees mentioned
NameTitleContext
Nurse JNurseWitnessed Resident 2 slapping Resident 1 and documented multiple incidents and falls.
Nurse KNurseDocumented witnessed fall of Resident 1 on 02/06/2025.
Nurse BNurseReported Resident 1's witnessed fall on 02/25/2025 and communicated with APS.
Nurse NNurseDocumented witnessed fall of Resident 2 on 04/27/2025 and reported to APS.
Nurse GHospice NurseMade APS report regarding Resident 2 slapping Resident 1 and discussed concerns with surveyor.
Caregiver HCaregiverWitnessed Resident 2 aggressively pushing Resident 1's wheelchair and expressed concern for Resident 1's safety.
Caregiver DCaregiverReported Resident 2 pushing Resident 1 and unplugged fall camera in Resident 1's room.
Social Worker FSocial WorkerReported concerns about Resident 2's treatment of Resident 1 and difficulty maintaining communication with family.
Administrator AAdministratorAcknowledged Resident 2's behaviors and lack of adequate fall prevention interventions.
Ombudsman EOmbudsmanObserved Resident 1's guarded posture and reported refusal of assistance navigating allegations of abuse.
APS Case Manager PAPS Case ManagerReported Resident 2's dementia diagnosis and activated power of attorney.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Apr 30, 2025

Visit Reason
Two complaint investigations and a verification visit were conducted to determine if New Perspective Sun Prairie was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.

Complaint Details
The visit was complaint-related, involving two complaint investigations and a verification visit to assess compliance. Specific substantiation status is not stated.
Findings
The Department issued a Statement of Deficiency (SOD #DS4J12) for violations of state statutes and administrative codes, resulting in a Notice of Violation, Special Orders requiring corrective actions including resident rights training, and a forfeiture of $1,400 imposed on the licensee.

Deficiencies (1)
Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in Statement of Deficiency (SOD) #DS4J12
Report Facts
Forfeiture amount: 1400 Reduced forfeiture amount: 910 Revisit inspection fee: 200 Compliance timeframe: 45 Payment timeframe: 10

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
Deficiencies: 0 Date: Apr 11, 2025

Visit Reason
A complaint investigation and verification visit was conducted on April 11, 2025, to determine if New Perspective Sun Prairie 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 and verification visit to assess compliance with applicable statutes and codes. The Department found violations substantiated as detailed in SOD #ZZI814.
Findings
The Department issued a Statement of Deficiency (SOD #ZZI814) 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 $1200.00. A revisit fee of $200 was also assessed following a verification visit on January 29, 2025.

Report Facts
Forfeiture amount: 1200 Reduced forfeiture amount: 780 Forfeiture component: 300 Forfeiture component: 900 Revisit inspection fee: 200 Compliance timeframe: 45 Appeal timeframe: 10

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: 29 Deficiencies: 2 Date: Jan 29, 2025

Visit Reason
The visit was conducted as a complaint investigation triggered by two complaints regarding medication administration practices and a verification visit at New Perspectives, a CBRF in Sun Prairie, WI.

Complaint Details
Two complaints were investigated; one complaint was substantiated related to medication administration practices. The investigation included review of medication administration records and interviews with residents and staff.
Findings
The survey found two violations of DHS Chapter 83, including failure to administer medications as prescribed and inadequate staffing leading to delayed response times to call lights. One complaint was substantiated, and eight prior violations were corrected.

Deficiencies (2)
Provider did not ensure residents received their medications in the dosage and at intervals prescribed by their practitioner, with multiple missed doses documented.
Provider did not ensure sufficient staff were provided to meet resident needs, resulting in residents waiting more than 25 minutes for assistance after using call light pendants.
Report Facts
Revisit fee: 200 Violations corrected: 8 Residents interviewed with delayed call light response: 3 Wait times in minutes: 109

Employees mentioned
NameTitleContext
Regional Nurse BBDiscussed medication administration concerns during exit interview
Facility Nurse CCFacility NurseProvided explanations for missed medications and staffing issues
Regional Director AARegional DirectorAcknowledged call light response improvements but noted further improvements needed

Inspection Report

Monitoring
Census: 31 Deficiencies: 0 Date: Dec 10, 2024

Visit Reason
The bureau of assisted living Southern regional office conducted a monitoring visit at New Perspective Sun Prairie, a CBRF located in Sun Prairie, WI.

Findings
No violations of DHS Chapter 83 were issued during the monitoring visit.

Report Facts
Violations issued: 0 Census: 31

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Nov 15, 2024

Visit Reason
A complaint investigation and self-report review were conducted to determine if New Perspective Sun Prairie 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 self-report review. The Department found violations sufficient to issue a Statement of Deficiency and impose a forfeiture.
Findings
The Department issued a Statement of Deficiency (SOD #DS4J11) for violations of state statutes and administrative codes related to the operation of the facility, including requirements for behavior management and medication administration. A forfeiture of $3,120.00 was imposed for these violations.

Report Facts
Forfeiture amount: 3120 Reduced forfeiture amount: 2028 Forfeiture amount: 150 Forfeiture amount: 500 Forfeiture amount: 900 Forfeiture amount: 770 Forfeiture amount: 800

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: 32 Capacity: 50 Deficiencies: 8 Date: Nov 15, 2024

Visit Reason
From 11/01/2024 to 11/15/2024, the bureau of assisted living southern regional office conducted a complaint investigation and self-report review at New Perspectives, a CBRF located in Sun Prairie, WI.

Complaint Details
Complaint was substantiated. The investigation included review of Resident 1's unwitnessed fall with head injury and laceration, elopement incidents, failure to report to the department within required timeframes, and inadequate supervision and behavioral management. Resident 2's medication administration issues and elopement were also investigated.
Findings
As a result of this survey, 8 violations from DHS Chapter 83 were identified, including failure to investigate injuries of unknown source, failure to report resident whereabouts when unknown, failure to report law enforcement involvement, and failure to supervise daily operations adequately. Medication management and behavioral management deficiencies were also noted.

Deficiencies (8)
Investigate injuries of unknown source
Reporting when resident's whereabouts unknown
Reporting when law enforcement is called
Administrator shall supervise daily operation
PRN psychotropic medication
Behavior management
Supervision
Medication administration
Report Facts
Violations identified: 8 Census: 32 Total capacity: 50 Medication doses not administered: 33 Medication doses administered: 3

Employees mentioned
NameTitleContext
Administrator AAdministratorNamed in findings related to failure to investigate injuries, failure to report elopement, and failure to supervise daily operations
Nurse ENurseNamed in findings related to medication administration and self-report filing
Caregiver BDocumented Resident 1's unwitnessed fall and injury
Caregiver JReported Resident 1's behavior and elopement attempts
Caregiver IReported Resident 1's behavior and elopement attempts
Nurse DNurseFiled self-reports related to Resident 1's elopement
Nurse GNurseDocumented inability to locate Resident 1 and self-report filing
Caregiver KReported Resident 1 found in Resident 2's bed
Doctor QPrimary Care ProviderReported not being notified of Resident 1's elopements and agitation medication status
Physician Assistant PPhysician AssistantReported medication orders and communication with facility

Inspection Report

Enforcement
Deficiencies: 6 Date: Sep 4, 2024

Visit Reason
The inspection was conducted to determine if New Perspective Sun Prairie was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities (CBRF). This document serves as a Notice of Violation and Order to Comply with Requirements based on findings from the inspection.

Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency (SOD #ZZI813). The licensee is ordered to comply immediately with requirements to protect residents' health and safety, including consultation with a registered nurse to develop corrective measures. A total forfeiture of $2,530.00 was imposed for specific violations.

Deficiencies (6)
Violation of Wis. Admin. Code 83.14(2)(a)
Violation of Wis. Admin. Code 83.32(3)(h)
Violation of Wis. Admin. Code 83.35(3)(d)
Violation of Wis. Admin. Code 83.36(1)(a)
Violation of Wis. Admin. Code 83.37(2)(d)
Violation of Wis. Admin. Code 83.37(1)(j)
Report Facts
Forfeiture amount: 2530 Reduced forfeiture amount: 1644.5 Inspection fee: 200 Forfeiture amount by tag: 500 Forfeiture amount by tag: 330 Forfeiture amount by tag: 500 Forfeiture amount by tag: 600 Forfeiture amount by tag: 200 Forfeiture amount by tag: 400

Inspection Report

Complaint Investigation
Census: 32 Capacity: 50 Deficiencies: 9 Date: Aug 28, 2024

Visit Reason
Surveyors conducted 4 complaint investigations, 2 self-report reviews, and a verification visit at New Perspective Sun Prairie, a CBRF located in Sun Prairie, WI, triggered by complaints and self-reports regarding medication administration, incident reporting, and facility compliance.

Complaint Details
Four complaints were investigated, with two complaints substantiated and two unsubstantiated. The complaints involved medication administration practices and facility compliance issues.
Findings
The investigation identified 10 deficiencies including failure to report serious injuries timely, medication administration errors, inadequate staffing leading to delayed resident assistance, failure to update individual service plans, improper medication storage and disposal, incomplete documentation of medication administration, and resident rooms with strong urine odors. Several deficiencies were repeat violations.

Deficiencies (9)
Failure to report a serious injury resulting in hospitalization within 3 working days.
Residents did not receive medications as prescribed, including missed doses and medications labeled 'med not available'.
Individual service plan not updated to include new resident behavior (crawling on floor).
Insufficient staff to meet resident needs, resulting in wait times over 25 minutes for assistance.
Failure to dispose of medications of deceased residents within 30 days.
Failure to maintain proof-of-use records for schedule II drugs with required details and signatures.
Failure to document medication administration at the time of administration, including missing initials and dates on narcotic blister packs.
Medication storage cabinets and carts were found unlocked and accessible to residents.
Resident rooms smelled strongly of urine due to refusal to use incontinence products and soiled clothing left in hampers.
Report Facts
Deficiencies identified: 10 Repeat deficiencies: 7 Complaints substantiated: 2 Complaints unsubstantiated: 2 Revisit fee: 200 Resident wait times (minutes): 81 Resident wait times (minutes): 85 Narcotic verification log signings: 11 Narcotic verification log signings: 41 Narcotic verification log signings: 45

Employees mentioned
NameTitleContext
Administrator AAdministratorAcknowledged failure to report serious injury timely, medication administration issues, unlocked medication cart, and resident room odor concerns.
Med Passer OObserved medication cart, acknowledged medication administration and storage issues, including unlabeled blister packs and missing documentation.
Nurse QHealth and Wellness Director / Triage NurseAcknowledged missed medication administration, failure to check after-hours medication drop-box, and medication documentation issues.
Caregiver XReported resident behavior of crawling on floor and lack of ISP update.
Caregiver OReported strong urine odors in resident rooms and refusal of incontinence products by residents.
Pharmacist WPharmacistDescribed pharmacy medication delivery process and communication with facility.

Inspection Report

Complaint Investigation
Deficiencies: 3 Date: May 15, 2024

Visit Reason
A complaint investigation and verification visit was conducted to determine if New Perspective Sun Prairie 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 after a complaint investigation. The Department found violations and issued enforcement actions including forfeitures and special orders.
Findings
The Department issued a Statement of Deficiency (SOD #ZZI812) citing violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in an order to comply with staffing requirements and other operational standards. A forfeiture of $1250 was imposed for specific violations, and a $200 inspection fee was assessed for a subsequent verification visit.

Deficiencies (3)
Violation of Wis. Admin. Code § DHS 83.36(1)(a) regarding staffing in sufficient numbers on a 24-hour basis to meet residents' needs.
Violation of Wis. Admin. Code § 83.35(3)(d).
Violation of Wis. Admin. Code § 83.38(1)(h).
Report Facts
Forfeiture amount: 1250 Forfeiture amount: 400 Forfeiture amount: 600 Forfeiture amount: 250 Inspection fee: 200 Compliance timeframe: 45 Forfeiture reduction percentage: 35 Forfeiture reduced amount: 812.5 Forfeiture payment deadline: 10

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

Inspection Report

Complaint Investigation
Census: 33 Capacity: 50 Deficiencies: 4 Date: May 8, 2024

Visit Reason
Surveyors conducted 2 complaint investigations and 4 verification visits at New Perspective Sun Prairie following complaints about individual service plan implementation and staffing adequacy.

Complaint Details
Two complaints were substantiated related to failure to follow individual service plans and inadequate staffing resulting in delayed call light responses.
Findings
The survey found 4 violations including failure to implement individual service plans for residents, inadequate staffing leading to delayed call light responses, and improper medication administration related to insulin dosing and timing.

Deficiencies (4)
Failure to implement and follow Resident 4's individual service plan regarding transfer and mobility needs.
Failure to update Resident 3's individual service plan to reflect changes in residual limb management after amputation.
Inadequate staffing evidenced by 38 occasions of call light response times exceeding 26 minutes between 05/02/2024 and 05/08/2024.
Improper insulin administration for Resident 3, including administering insulin post-meal instead of pre-meal and incorrect dosing without documented medical guidance for blood sugar levels exceeding prescribed sliding scale.
Report Facts
Revisit fee: 200 Number of violations: 4 Call light response delays: 38 Facility capacity: 50 Current census: 33 Insulin dosing errors: 2 High blood sugar events: 6

Employees mentioned
NameTitleContext
Administrator AAdministratorAcknowledged issues with call light response times, individual service plan implementation, and insulin administration errors.
Caregiver ICaregiverObserved administering insulin to Resident 3 post-meal and reported misunderstanding about Resident 3's lunch.
Caregiver LCaregiverInterviewed regarding Resident 4's mobility assistance and residual limb care for Resident 3.
Caregiver JCaregiverConfirmed Resident 3 ate lunch in the main dining area.
Nurse KNurseFrom Resident 3's medical provider office, explained proper blood sugar testing and insulin administration protocol.
Life Engagement Coach MLife Engagement CoachReported Resident 4 ambulated without staff assistance.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Oct 12, 2023

Visit Reason
Two complaint investigations were concluded to determine if New Perspective Sun Prairie was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.

Complaint Details
The visit was complaint-related, concluding two complaint investigations to assess compliance with statutory and administrative requirements for community-based residential facilities. The Department issued enforcement actions based on these investigations.
Findings
The Department issued a Statement of Deficiency for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation, an Order to Comply, Special Orders requiring corrective measures, and an imposed forfeiture of $800.

Deficiencies (1)
Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in Statement of Deficiency #ZZI811
Report Facts
Forfeiture amount: 800 Reduced forfeiture amount: 520 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: 32 Capacity: 50 Deficiencies: 6 Date: Oct 12, 2023

Visit Reason
The Bureau of Assisted Living conducted two complaint investigations at New Perspective Sun Prairie, a community-based residential facility, due to allegations including abuse, neglect, and misappropriation of property.

Complaint Details
Two complaint investigations were conducted; one complaint was substantiated and one was unsubstantiated. The substantiated complaint involved failure to investigate and document caregiver misappropriation of Resident 2's phone and data usage.
Findings
Six deficiencies were identified, including failure to investigate and document allegations of caregiver misappropriation, failure to investigate injuries of unknown source, failure to notify legal representatives of incidents, failure to update individual service plans to reflect fall prevention needs, and failure to provide a written grievance summary. Two deficiencies were repeat.

Deficiencies (6)
Caregiver failed to investigate and document allegation of stealing Resident 2's phone and misuse of data.
Failure to investigate injuries of unknown source sustained by Resident 1 on two occasions.
Failure to notify Resident 1's legal representative and physician of injury incidents.
Failure to provide a written summary of grievance findings, conclusions, and actions to Resident 2's guardian.
Failure to update Resident 1's individual service plan to reflect changes in fall prevention needs after documented falls.
Failure to monitor Resident 1's health adequately after falls and skin tears, including failure to implement effective fall prevention interventions.
Report Facts
Deficiencies identified: 6 Repeat deficiencies: 2 Residents served: 32 Total capacity: 50 Data usage: 39

Employees mentioned
NameTitleContext
Administrator AProvided information and correspondence related to investigations and grievances.
Family Member EActivated power of attorney for Resident 1 and provided information about resident's condition and grievances.
Nurse BReported on Resident 1's injuries, falls, and skin tears, and provided documentation.
Caregiver GNamed in misappropriation investigation related to Resident 2's phone and data.
Caregiver HNamed in misappropriation investigation related to Resident 2's phone and data.
RN FMentioned in correspondence regarding grievances of Resident 2.

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Sep 5, 2023

Visit Reason
A verification visit, standard survey, and complaint investigation were conducted to determine if New Perspective Sun Prairie 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 complaint investigation as part of the verification and standard survey process. Specific substantiation status is not stated.
Findings
The Department issued a Statement of Deficiency (SOD #9PKX12) for violations of state statutes and administrative codes. A total forfeiture of $1600 was imposed for these violations, with some forfeitures accruing daily until compliance is achieved. Additionally, a $200 inspection fee for a revisit was assessed to verify correction of prior violations.

Report Facts
Forfeiture amount: 1600 Reduced forfeiture amount: 1040 Forfeiture breakdown: 1000 Forfeiture breakdown: 400 Forfeiture breakdown: 200 Inspection fee: 200 Compliance timeframe: 45 Appeal timeframe: 10

Inspection Report

Routine
Census: 30 Deficiencies: 4 Date: Sep 5, 2023

Visit Reason
The Bureau of Assisted Living conducted a standard licensing survey, complaint investigation, and verification visit at New Perspective Sun Prairie, a CBRF located in Sun Prairie, WI.

Complaint Details
The complaint investigation was unsubstantiated.
Findings
Four violations of Chapter DHS 83 were issued, including deficiencies in employee training, continuing education, individual service plan updates, and medication administration documentation. The complaint was unsubstantiated, and a $200 revisit fee was assessed.

Deficiencies (4)
Provider did not ensure that 3 of 3 employees reviewed completed training in resident rights, client group, or challenging behaviors within 90 days after starting employment.
Provider did not ensure 2 of 3 employees completed at least 15 hours of continuing education in 2022.
Provider did not ensure that 2 of 2 resident individual service plans were updated to include the rationale for use of PRN psychotropic medications.
Provider did not ensure accurate documentation of medication administration for 2 of 3 residents; several administration entries were undocumented in August 2023.
Report Facts
Violations issued: 4 Revisit fee: 200 Census: 30 Continuing education hours: 15 Documented continuing education hours for Caregiver G: 3 Documented continuing education hours for Caregiver F: 0

Employees mentioned
NameTitleContext
Administrator AInterviewed regarding training deficiencies and medication administration documentation.
Caregiver FDid not complete required training in resident rights, client group, challenging behaviors, and continuing education.
Caregiver GDid not complete required training in resident rights and had insufficient continuing education hours.
Caregiver HDid not complete required training in resident rights.

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Mar 14, 2023

Visit Reason
The Bureau of Assisted Living, Southern Regional Office conducted a complaint investigation at New Perspective Sun Prairie, a CBRF located in Sun Prairie, WI.

Complaint Details
The complaint was not substantiated.
Findings
As a result of the investigation, 0 violations of Chapter DHS 83 were issued. The complaint was not substantiated.

Report Facts
Violations issued: 0

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