Deficiencies (last 3 years)
Deficiencies (over 3 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/year
Deficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
47 residents
Based on a December 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Date: Dec 11, 2025
Visit Reason
Surveyor investigated one complaint, reviewed one self-report, and conducted a standard survey at Courtyard at Oshkosh.
Complaint Details
One complaint was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no new deficiencies were identified as a result of the survey.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Jul 11, 2025
Visit Reason
Surveyor conducted a complaint investigation at Courtyard at Oshkosh.
Complaint Details
Complaint was unsubstantiated.
Findings
No deficiencies were identified and the complaint was unsubstantiated.
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
Date: Jun 13, 2025
Visit Reason
Surveyor conducted two complaint investigations at Courtyard At Oshkosh.
Complaint Details
Two complaints were investigated and found to be unsubstantiated.
Findings
Two complaints were unsubstantiated and no deficiencies were identified.
Report Facts
Number of complaints investigated: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 13, 2025
Visit Reason
Surveyor conducted 2 complaints at Courtyard at Oshkosh, a CBRF located in Oshkosh, WI.
Complaint Details
Two complaints were investigated and both were found to be unsubstantiated with no violations issued.
Findings
As a result of the investigation, 0 violations of Chapter DHS 83 were issued. Both complaints were unsubstantiated.
Report Facts
Complaints investigated: 2
Violations issued: 0
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
Surveyor conducted 2 complaint investigations at The Courtyard At Oshkosh.
Complaint Details
Two complaints were investigated and both were found to be unsubstantiated.
Findings
No deficiencies were identified. Two of 2 complaints were unsubstantiated.
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Date: Apr 10, 2024
Visit Reason
Surveyor conducted a complaint investigation at Courtyard at Oshkosh (The) on 04/10/2024 with additional information gathered through 04/12/2024.
Complaint Details
Complaint was unsubstantiated and no deficiencies were identified.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the investigation.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Date: Mar 18, 2024
Visit Reason
Surveyor conducted two complaint investigations at Courtyard At Oshkosh on 03/18/2024, with additional information gathered through 03/19/2024.
Complaint Details
Two complaints were investigated and both were found to be unsubstantiated.
Findings
No deficiencies were identified as a result of the survey, and both complaints were unsubstantiated.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Date: Aug 21, 2023
Visit Reason
Surveyors conducted one complaint investigation, a verification visit, and reviewed one self-report at Courtyard at Oshkosh.
Complaint Details
One complaint was investigated and found to be unsubstantiated.
Findings
All previous deficiencies were corrected, one complaint was unsubstantiated, and no new deficiencies were identified.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 11, 2023
Visit Reason
A standard survey and complaint investigation were conducted to determine if Courtyard at Oshkosh 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 standard survey. The report does not specify substantiation status.
Findings
The Department issued a Statement of Deficiency (SOD #8SWM11) for violations of Wisconsin Statutes and Administrative Code requirements, establishing grounds for enforcement action and requiring the licensee to comply with standards to protect resident health, safety, and welfare.
Report Facts
Compliance correction timeframe: 45
Inspection fee: 200
Appeal filing timeframe: 10
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen D. Lyons | Interim 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: 45
Deficiencies: 6
Date: May 5, 2023
Visit Reason
Surveyor conducted an on-site complaint investigation and a standard survey at Courtyard at Oshkosh on 05/05/2023, with additional information gathered through 05/11/2023. The complaint was unsubstantiated.
Complaint Details
Complaint was unsubstantiated.
Findings
Six deficiencies were identified related to employee communicable disease screening, department-approved training courses, resident health screening, initial evacuation evaluation, and out-of-state background checks. Specific failures included lack of timely communicable disease screening for an employee, missing required training for another employee, missing tuberculosis screening for a resident, late evacuation evaluation, and missing out-of-state background check for an employee.
Deficiencies (6)
Provider did not ensure 1 of 3 employees (Caregiver C) was screened for clinically apparent communicable disease within 90 days before employment.
Provider did not ensure Caregiver D obtained department-approved training in fire safety and first aid and choking within 90 days after starting employment.
Provider did not ensure Caregiver D obtained training in resident rights within 90 days after starting employment.
Provider did not ensure Resident 1 was screened for tuberculosis within 90 days before or 7 days after admission; TB screen was over 1 year late.
Provider did not ensure an initial evacuation evaluation was completed for Resident 2 within 3 days of admission; evaluation was over 8 days past due.
Provider did not obtain an out-of-state background check for Caregiver C, who resided in another state within the past 3 years.
Report Facts
Deficiencies identified: 6
Census: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver C | Named in deficiency for lack of communicable disease screening and missing out-of-state background check. | |
| Caregiver D | Named in deficiencies for missing department-approved training in fire safety, first aid, choking, and resident rights. | |
| Administrator A | Interviewed multiple times regarding missing documentation and deficiencies. | |
| Wellness Director B | Interviewed regarding Resident 1's tuberculosis screening. |
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