Inspection Report Summary
The most recent inspection on October 15, 2025, found no deficiencies and the complaint investigated was unsubstantiated. Earlier inspections showed a mostly clean record, though a complaint investigation in May 2025 identified a deficiency related to inadequate personal care services, specifically insufficient bathing frequency and failure to follow the care plan intervention to contact the activated power of attorney. This issue resulted in a Statement of Deficiency and an order to achieve substantial compliance within 45 days. Other complaint investigations prior to that were unsubstantiated and did not result in deficiencies. The facility’s inspection history suggests improvement following the May 2025 findings, with no deficiencies noted in the most recent review.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
0.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
93% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
55 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Date: Oct 15, 2025
Visit Reason
A verification visit and complaint investigation was conducted at Aspire Oshkosh on 10/15/2025 with additional information gathered through 10/16/2025.
Complaint Details
The complaint was unsubstantiated.
Findings
The previous deficiency was corrected and no new deficiencies were identified during the visit. The complaint was unsubstantiated.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: May 21, 2025
Visit Reason
Surveyor conducted a complaint investigation at Aspire Oshkosh CBRF due to concerns about personal care services provided to Resident 1.
Complaint Details
The complaint was substantiated. Resident 1 was not provided baths/showers as required, and the facility did not implement the intervention to call APOA after refusals as stated in the care plan.
Findings
The investigation found that Resident 1, who required assistance with bathing twice weekly, only received 8 documented showers over a two-and-a-half-month period. The facility failed to follow the Individualized Service Plan intervention to call the Activated Power of Attorney (APOA) when Resident 1 refused bathing, and there was no documentation that APOA was contacted as required.
Deficiencies (1)
Failure to ensure personal care services were provided to meet the needs of Resident 1, including inadequate bathing frequency and failure to follow the care plan intervention to contact APOA when Resident 1 refused bathing.
Report Facts
Census: 54
Documented showers: 8
Bathing frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON-C | Director of Nursing | Verified receipt of text messages from APOA-A and followed up with staff regarding bathing concerns |
| DON-B | Director of Nursing | Verified bathing policy and lack of documentation for Resident 1's baths/showers |
| APOA-A | Activated Power of Attorney for Resident 1 who reported concerns about bathing and was not contacted as required | |
| RA-D | Resident Assistant | Interviewed regarding bathing schedule and documentation |
| CNA-E | Certified Nursing Assistant | Mentioned in relation to Resident 1's refusal of baths/showers and lack of documentation |
Notice
Deficiencies: 0
Date: May 21, 2025
Visit Reason
The document serves as a Notice of Violation and Order to Comply following a complaint investigation to determine if Aspire Oshkosh was in substantial compliance with applicable state statutes and administrative codes governing community-based residential facilities.
Complaint Details
Complaint investigation concluded on May 21, 2025, to determine compliance; violations were found and substantiated as indicated by issuance of Statement of Deficiency #JKZ311.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in the issuance of Statement of Deficiency #JKZ311 and an order for the licensee to achieve and maintain substantial compliance within 45 days.
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 |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Date: Nov 18, 2024
Visit Reason
Surveyor conducted a standard survey, one complaint investigation, and a facility self-report at Aspire Oshkosh.
Complaint Details
One (1) of 1 complaint was unsubstantiated.
Findings
One complaint was unsubstantiated and no deficiencies were issued as a result of the survey.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Date: May 30, 2023
Visit Reason
Surveyor conducted a complaint investigation at Aspire Oshkosh based on a complaint received.
Complaint Details
Complaint investigation was unsubstantiated with no deficiencies found.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the investigation.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Date: Apr 27, 2023
Visit Reason
Surveyor conducted a complaint investigation at Aspire Oshkosh based on a complaint received.
Complaint Details
Complaint investigation was unsubstantiated with no deficiencies found.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the investigation.
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