Inspection Reports for American Grand Assisted Living Suites

900 MEADOW LN, NEENAH, WI, 54956

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 6.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

37% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/year

Deficiencies per year

4 3 2 1 0
2023
2024
2025

Census

Latest occupancy rate 72 residents

Based on a September 2025 inspection.

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

Census over time

49 56 63 70 77 Apr 2023 Jul 2024 Feb 2025 Sep 2025
Inspection Report Complaint Investigation Deficiencies: 0 Sep 23, 2025
Visit Reason
A complaint investigation and verification visit were conducted to determine if American Grand Assisted Living Suites was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #8IN915) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. An $800 forfeiture was imposed for violations identified, and the licensee was ordered to comply immediately and implement corrective measures.
Complaint Details
The visit was complaint-related, conducted to verify compliance with applicable statutes and administrative codes. The Department found violations resulting in a Statement of Deficiency and imposed a forfeiture.
Report Facts
Forfeiture amount: 800 Reduced forfeiture amount: 520 Inspection fee: 200 Revisit fee: 200 Compliance timeframe: 45 Extension request timeframe: 10 Forfeiture payment timeframe: 10
Employees Mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter.
Vicky WittmanAssisted Living Regional DirectorContact person for questions about the letter.
Inspection Report Complaint Investigation Census: 72 Deficiencies: 1 Sep 22, 2025
Visit Reason
Surveyor conducted an onsite visit to investigate 3 complaints and conduct a verification visit at American Grand Assisted Living Suites. Additional information was received through 09/23/2025.
Findings
One of three complaints was substantiated and one new deficiency was identified. The provider failed to ensure implementation of individual service plans for Resident 8 regarding shower acceptance and for Resident 12 regarding room cleanliness, including unclean bedding, food left on bed, and an unclean cat litter box.
Complaint Details
Three complaints were investigated; one complaint was substantiated related to failure to implement ISPs for Residents 8 and 12. Resident 8 frequently refused showers and staff did not follow ISP interventions. Resident 12's room was found dirty with old food on bed and an unclean litter box, confirmed by interviews and observations.
Deficiencies (1)
Description
Provider did not ensure all individual service plans (ISPs) were implemented and followed, specifically interventions to increase Resident 8's acceptance of showers and maintain cleanliness of Resident 12's room and cat litter box.
Report Facts
Complaints investigated: 3 Complaints substantiated: 1 Previous deficiencies corrected: 3 Revisit fee: 200 Census: 72
Employees Mentioned
NameTitleContext
Caregiver HCaregiverPreferred caregiver of Resident 8, mentioned in relation to shower interventions
Caregiver PCaregiverInterviewed regarding shower refusals and inaccurate charting for Resident 8
Caregiver QCaregiverInterviewed about shower interventions and Resident 8's refusal
Caregiver RCaregiverInterviewed about shower refusals for Resident 8 and room cleaning for Resident 12
RN BRegistered NurseManagement team member acknowledging issues with Resident 8's shower care
Administrator AAdministratorManagement team member acknowledging concerns and room condition for Resident 12
Inspection Report Complaint Investigation Census: 68 Deficiencies: 3 Jul 14, 2025
Visit Reason
The surveyor conducted an onsite visit to investigate one complaint and to complete verification visits for two prior Statements of Deficiency dated 02/19/2025 and 11/27/2024. The complaint was substantiated.
Findings
The investigation found multiple repeat deficiencies including failure to update Resident 8's individual service plan to address shower refusals, failure to ensure medication administration needs were met with medications missing from the medication cart, and staff mistreatment of residents by Caregivers G and H. The facility had not assessed root causes for shower refusals or updated care plans accordingly. Medication administration documentation was inaccurate and medications were unavailable. Caregivers were reported to be verbally disrespectful and involved in a physical altercation.
Complaint Details
The complaint was substantiated and involved concerns about the provider's response to shower refusals, medication administration and documentation, and mistreatment of residents by staff.
Deficiencies (3)
Description
Resident 8's individual service plan was not updated to address persistent shower refusals and lacked strategies to encourage acceptance of showers.
Resident 8's medication administration needs were not met; aspirin and omega 3 medications were missing from the medication cart and refusals were documented inaccurately.
Caregivers G and H did not treat residents with courtesy, respect, and dignity; incidents included verbal disrespect and a physical altercation between staff in a resident's room.
Report Facts
Revisit fee: 200 Deficiencies uncorrected: 3 New deficiencies identified: 3 Medication refusals documented: 10 Medication refusals documented: 5
Employees Mentioned
NameTitleContext
Caregiver GCaregiverNamed in findings related to mistreatment of residents and prior deficiency.
Caregiver HCaregiverNamed in findings related to mistreatment of residents, verbal disrespect, refusal to assist with transfers, and involvement in physical altercation.
Caregiver JCaregiverInterviewed regarding concerns about Caregivers G and H and medication administration.
Caregiver ICaregiverInterviewed regarding concerns about Caregiver H's behavior and Resident 8's care.
Caregiver NCaregiverInterviewed regarding medication administration and documentation.
Administrator AAdministratorInterviewed regarding shower refusals, medication administration, and staff behavior.
Registered Nurse BRegistered NurseInterviewed regarding shower refusals, medication administration, and staff behavior.
Manager MManagerInterviewed regarding shower refusals and medication administration.
Caregiver OCaregiverInvolved in physical altercation with Caregiver H.
Behavioral Health Specialist LBehavioral Health SpecialistInterviewed regarding staff approaches to residents prone to refuse care.
Inspection Report Complaint Investigation Deficiencies: 1 Jul 14, 2025
Visit Reason
A complaint investigation and verification visit were conducted on July 14, 2025, to determine if American Grand Assisted Living Suites was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #8IN914) citing 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 resident rights training, and a total forfeiture of $1,400.00. A $200 inspection fee was also assessed for a verification visit.
Complaint Details
The visit was complaint-related, conducted to verify compliance with applicable statutes and codes. The Department found violations and issued enforcement actions including forfeitures and orders.
Deficiencies (1)
Description
Violation of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #8IN914
Report Facts
Forfeiture amount: 1400 Reduced forfeiture amount: 910 Forfeiture breakdown: 600 Forfeiture breakdown: 200 Forfeiture breakdown: 600 Inspection fee: 200 Compliance timeframe: 45 Appeal timeframe: 10 Forfeiture payment timeframe: 10 Revisit fee payment timeframe: 10
Employees Mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Vicky WittmanAssisted Living Regional DirectorContact person for questions about the letter
Inspection Report Complaint Investigation Deficiencies: 0 Feb 19, 2025
Visit Reason
A complaint investigation, standard survey, and verification visit were conducted to determine if American Grand Assisted Living Suites was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD) #8IN913 for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply immediately with requirements to protect resident health, safety, and welfare, including training staff and providing documentation to legal representatives. A forfeiture of $500 was imposed for violations.
Complaint Details
The visit was complaint-related, involving a complaint investigation, standard survey, and verification visit to assess compliance with applicable statutes and codes.
Report Facts
Forfeiture amount: 500 Reduced forfeiture amount: 325 Inspection fee: 200 Compliance timeframe: 45 Documentation timeframe: 7 Payment timeframe: 10
Employees Mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter as Bureau of Assisted Living, Division of Quality Assurance.
Vicky WittmanAssisted Living Regional DirectorContact person for questions about the letter.
Inspection Report Complaint Investigation Census: 63 Deficiencies: 2 Feb 17, 2025
Visit Reason
The surveyor investigated one complaint alleging residents were not being administered medications appropriately, conducted a standard survey, and a verification visit.
Findings
The complaint was unsubstantiated. However, two new deficiencies were identified during the standard survey, including a repeat violation related to medication administration and treatment. Caregiver G did not ensure Resident 7 ingested medication prior to leaving the room and was observed treating Resident 7 without courtesy and respect, causing discomfort.
Complaint Details
The complaint alleged residents were not being administered medications appropriately. The complaint was investigated and found unsubstantiated.
Deficiencies (2)
Description
Provider did not provide medication administration appropriate to meet Resident 7's needs by not verifying ingestion prior to leaving the room.
Provider did not ensure residents were treated with courtesy, respect, and full recognition of dignity and individuality for Resident 7; this is a repeat deficiency.
Report Facts
Revisit fee: 200 Residents reviewed: 3 Deficiencies identified: 2 Past deficiencies corrected: 4
Employees Mentioned
NameTitleContext
Caregiver GNamed in findings related to medication administration and treatment deficiencies involving Resident 7
Administrator AInterviewed regarding medication administration and treatment concerns for Resident 7
Registered Nurse BRN-BInterviewed regarding medication administration and treatment concerns for Resident 7
Inspection Report Complaint Investigation Deficiencies: 0 Nov 27, 2024
Visit Reason
A complaint investigation was conducted on November 27, 2024, to determine if American Grand Assisted Living Suites was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #E48B11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation and an imposed forfeiture totaling $900.00.
Complaint Details
Complaint investigation concluded on November 27, 2024, resulting in findings of noncompliance and issuance of Statement of Deficiency #E48B11.
Report Facts
Forfeiture amount: 900 Forfeiture amount: 500 Forfeiture amount: 400 Days to achieve compliance: 45 Days to request extension: 10 Days to pay forfeiture: 10 Reduced forfeiture percentage: 35 Reduced forfeiture amount: 585
Employees Mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Vicky WittmanAssisted Living Regional DirectorContact person for questions about the letter
Inspection Report Complaint Investigation Census: 67 Deficiencies: 3 Nov 21, 2024
Visit Reason
The surveyor conducted two complaint investigations at American Grand Assisted Living Suites based on concerns received regarding admission agreements and service plans.
Findings
Three deficiencies were identified, including a repeat violation. Deficiencies involved incomplete admission agreements missing service charge rates, failure to update individualized service plans (ISP) to reflect changes in resident needs and behaviors, and inadequate documentation of PRN psychotropic medications on ISPs for two residents.
Complaint Details
Two complaints were investigated; two of two complaints were unsubstantiated. One deficiency was a repeat violation from prior statements of deficiency dated 2019, 2021, and 2022.
Deficiencies (3)
Description
Admission agreement did not include the rate charged for basic services for 1 of 2 residents.
Individualized Service Plan (ISP) was not updated to reflect changes in needs and behaviors for 1 of 2 residents reviewed, including behaviors of placing self on the floor.
PRN psychotropic medications were not documented on the ISP for 2 residents, lacking rationale for use and detailed behavior descriptions.
Report Facts
Deficiencies identified: 3 Residents reviewed: 2 Repeat citations: 5 Census: 67
Employees Mentioned
NameTitleContext
Administrator AInterviewed regarding missing service fees in admission agreement and ISP documentation.
South Director BInterviewed regarding ISP documentation and medication review.
Inspection Report Complaint Investigation Deficiencies: 0 Jul 30, 2024
Visit Reason
A complaint investigation and verification visit were conducted on July 30, 2024, to determine if American Grand Assisted Living Suites 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 (SOD) #8IN912 and imposed a total forfeiture of $2,530.00. The licensee was ordered to comply with requirements immediately and implement corrective measures to ensure proper care and treatment of residents.
Complaint Details
The visit was complaint-related, conducted to verify compliance with applicable statutes and administrative codes. The Department issued a Statement of Deficiency #8IN912 and imposed forfeitures for violations found during the investigation.
Report Facts
Forfeiture amount: 2530 Reduced forfeiture amount: 1644.5 Forfeiture amount: 1520 Forfeiture amount: 500 Forfeiture amount: 310 Forfeiture amount: 200 Inspection fee: 200 Compliance timeframe: 45 Appeal timeframe: 10
Employees Mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Vicky WittmanAssisted Living Regional DirectorContact person for questions about the letter
Inspection Report Complaint Investigation Census: 63 Capacity: 72 Deficiencies: 4 Jul 24, 2024
Visit Reason
Surveyors conducted 7 complaint investigations and a verification visit due to complaints alleging concerns with medication administration and call light response times.
Findings
Four deficiencies were identified including repeated medication administration failures, lack of written grievance summaries, incomplete medication administration documentation, and inadequate response to call lights resulting in resident neglect and safety concerns.
Complaint Details
Seven complaints were investigated; four were substantiated including medication administration failures and inadequate call light response times. Complaints included long wait times for assistance, medication not available, and lack of grievance documentation.
Deficiencies (4)
Description
Residents did not receive medications in the dosage and intervals prescribed, including morphine, Senna, Buprenorphine, aspirin, insulin, atorvastatin, iron supplement, baclofen, and alprazolam due to medication unavailability.
Provider did not provide a written summary of grievance findings, conclusions, and actions to Resident 1's legal representative.
Medication administration records (MAR) were not consistently initialed by staff for multiple residents, indicating incomplete documentation of medication administration.
Resident 2 experienced long wait times for call light response, sometimes over an hour, resulting in unmet toileting needs and distress, with documented complaints from the resident and power of attorney.
Report Facts
Complaint investigations: 7 Substantiated complaints: 4 Unsubstantiated complaints: 3 Deficiencies identified: 4 Repeat violations: 2 Census: 63 Total capacity: 72 Call light response times exceeding 20 minutes: 22 Longest call light response time: 140
Employees Mentioned
NameTitleContext
Operations Administrator AOperations AdministratorInterviewed regarding call light response times and grievance documentation.
Registered Nurse BRegistered NurseInterviewed regarding medication administration and documentation.
Hospice RN DHospice Registered NurseInterviewed regarding hospice medication administration and Resident 1's care.
Caregiver FCaregiverInterviewed regarding medication availability and Resident 1's care.
Power of Attorney for Healthcare EPower of Attorney for HealthcareInterviewed regarding Resident 1's medication and hospital transfer.
Power of Attorney CPower of AttorneyInterviewed regarding Resident 2's care concerns and call light response issues.
Inspection Report Complaint Investigation Deficiencies: 1 Oct 11, 2023
Visit Reason
A complaint investigation was conducted on October 11, 2023, to determine if American Grand Assisted Living Suites was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #8IN911) for violations related to medication administration and documentation deficiencies. Enforcement actions include a forfeiture totaling $1,820.00 with a reduced payment option of $1,183.00 if not appealed.
Complaint Details
The complaint investigation concluded that the facility was not in substantial compliance with Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83, resulting in issuance of SOD #8IN911.
Deficiencies (1)
Description
Medication administration and documentation deficiencies identified in Statement of Deficiency 8IN911.
Report Facts
Forfeiture amount: 1820 Reduced forfeiture amount: 1183 Forfeiture amount: 1620 Forfeiture amount: 200 Compliance timeframe: 45 Notification timeframe: 14 Payment timeframe: 10
Employees Mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter.
Vicky WittmanAssisted Living Regional DirectorContact person for questions about the letter.
Inspection Report Complaint Investigation Census: 64 Deficiencies: 3 Oct 6, 2023
Visit Reason
The surveyor conducted 4 complaint investigations at American Grand Assisted Living Suites due to allegations that residents did not receive prescribed medications and other care concerns.
Findings
Three deficiencies were identified, including failure to administer prescribed medications timely to a resident, unclean and odorous shared resident rooms, and failure to assist a resident with incontinence in a timely and respectful manner. Three out of four complaints were substantiated, with some deficiencies being repeat violations.
Complaint Details
The complaint investigation was triggered by allegations that residents did not receive prescribed medications and were left sitting in urine during incontinence episodes. Three out of four complaints were substantiated.
Deficiencies (3)
Description
Failure to administer prescribed antibiotics (amoxicillin and Bactrim) to Resident 5 from 06/23/2023 to 07/06/2023.
Two shared resident rooms had a strong urine-like odor and were not cleaned properly, with floors dirty and sticky.
Resident 1 was not treated with courtesy and respect; staff failed to assist the resident promptly during an incontinence episode, leaving the resident sitting in urine.
Report Facts
Number of complaints investigated: 4 Number of deficiencies identified: 3 Number of substantiated complaints: 3 Resident census: 64
Employees Mentioned
NameTitleContext
Regional Director of Operations (RDO) AInterviewed regarding delay in medication administration and staff redirection.
South Director (SD) BObserved staff ignoring resident incontinence and discussed concerns with staff.
Power of Attorney (POA) C for Resident 6Reported observations of residents sitting in urine and feces due to lack of staff assistance.
Inspection Report Complaint Investigation Deficiencies: 0 Apr 17, 2023
Visit Reason
A standard survey, verification visit, and complaint investigation were conducted to determine if American Grand Assisted Living Suites was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #QP0C16) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A verification visit was later conducted to determine if prior violations were corrected, resulting in a $200 inspection fee assessment.
Complaint Details
The visit included a complaint investigation to assess compliance with regulatory requirements; specific substantiation status is not stated.
Report Facts
Inspection fee: 200 Appeal filing period: 10 Compliance correction period: 45
Employees Mentioned
NameTitleContext
Kathleen D. LyonsInterim Assisted Living DirectorSigned the notice letter
Vicky WittmanAssisted Living Regional DirectorContact person for questions about the letter
Inspection Report Complaint Investigation Census: 56 Deficiencies: 1 Apr 11, 2023
Visit Reason
Surveyors conducted onsite visits on 04/11/2023 and 04/12/2023 to complete a standard survey, a verification visit, and five complaint investigations at American Grand Assisted Living Suites.
Findings
Eight of eight previous deficiencies were corrected and four of five complaints were unsubstantiated. One new deficiency was identified related to failure to immediately notify a resident's power of attorney of a significant change in condition.
Complaint Details
The complaint received in December 2022 alleged the provider did not provide appropriate health monitoring for a resident during June 2021. Four of five complaints were unsubstantiated. The substantiated complaint involved delayed notification to Resident 1's POA regarding increased pain after a fall on 05/01/2021.
Deficiencies (1)
Description
The provider did not immediately notify Resident 1's power of attorney for health care when the resident experienced a significant change in physical condition related to increased pain on 05/02/2021.
Report Facts
Revisit fee: 200 Previous deficiencies corrected: 8 Complaints investigated: 5 Complaints unsubstantiated: 4 New deficiencies identified: 1 Census: 56
Employees Mentioned
NameTitleContext
Administrator BAdministratorAcknowledged delayed response to Resident 1's increased pain and explained corrections made in health monitoring and notification.
POA APower of attorney for Resident 1, interviewed regarding notification delays.

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