Inspection Reports for The Courtyard at Oshkosh

WI

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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
2023
2024
2025

Census

Latest occupancy rate 47 residents

Based on a December 2025 inspection.

Census over time

40 45 50 55 60 May 2023 Mar 2024 Sep 2024 Jul 2025 Dec 2025
Inspection Report Complaint Investigation Census: 47 Deficiencies: 0 Dec 11, 2025
Visit Reason
Surveyor investigated one complaint, reviewed one self-report, and conducted a standard survey at Courtyard at Oshkosh.
Findings
The complaint was unsubstantiated and no new deficiencies were identified as a result of the survey.
Complaint Details
One complaint was investigated and found to be unsubstantiated.
Inspection Report Complaint Investigation Census: 48 Deficiencies: 0 Jul 11, 2025
Visit Reason
Surveyor conducted a complaint investigation at Courtyard at Oshkosh.
Findings
No deficiencies were identified and the complaint was unsubstantiated.
Complaint Details
Complaint was unsubstantiated.
Inspection Report Complaint Investigation Census: 49 Deficiencies: 0 Jun 13, 2025
Visit Reason
Surveyor conducted two complaint investigations at Courtyard At Oshkosh.
Findings
Two complaints were unsubstantiated and no deficiencies were identified.
Complaint Details
Two complaints were investigated and found to be unsubstantiated.
Report Facts
Number of complaints investigated: 2
Inspection Report Complaint Investigation Deficiencies: 0 Jan 13, 2025
Visit Reason
Surveyor conducted 2 complaints at Courtyard at Oshkosh, a CBRF located in Oshkosh, WI.
Findings
As a result of the investigation, 0 violations of Chapter DHS 83 were issued. Both complaints were unsubstantiated.
Complaint Details
Two complaints were investigated and both were found to be unsubstantiated with no violations issued.
Report Facts
Complaints investigated: 2 Violations issued: 0
Inspection Report Complaint Investigation Census: 45 Deficiencies: 0 Sep 19, 2024
Visit Reason
Surveyor conducted 2 complaint investigations at The Courtyard At Oshkosh.
Findings
No deficiencies were identified. Two of 2 complaints were unsubstantiated.
Complaint Details
Two complaints were investigated and both were found to be unsubstantiated.
Inspection Report Complaint Investigation Census: 51 Deficiencies: 0 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.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the investigation.
Complaint Details
Complaint was unsubstantiated and no deficiencies were identified.
Inspection Report Complaint Investigation Census: 53 Deficiencies: 0 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.
Findings
No deficiencies were identified as a result of the survey, and both complaints were unsubstantiated.
Complaint Details
Two complaints were investigated and both were found to be unsubstantiated.
Inspection Report Complaint Investigation Census: 47 Deficiencies: 0 Aug 21, 2023
Visit Reason
Surveyors conducted one complaint investigation, a verification visit, and reviewed one self-report at Courtyard at Oshkosh.
Findings
All previous deficiencies were corrected, one complaint was unsubstantiated, and no new deficiencies were identified.
Complaint Details
One complaint was investigated and found to be unsubstantiated.
Report Facts
Revisit fee: 200
Inspection Report Complaint Investigation Deficiencies: 0 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.
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.
Complaint Details
The visit was complaint-related and included a standard survey. The report does not specify substantiation status.
Report Facts
Compliance correction timeframe: 45 Inspection fee: 200 Appeal filing timeframe: 10 Posting duration: 90
Employees Mentioned
NameTitleContext
Kathleen D. LyonsInterim Assisted Living DirectorSigned the Notice and Order letter
Vicky WittmanAssisted Living Regional DirectorContact person for questions about the letter
Inspection Report Complaint Investigation Census: 45 Deficiencies: 6 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.
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.
Complaint Details
Complaint was unsubstantiated.
Deficiencies (6)
Description
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
NameTitleContext
Caregiver CNamed in deficiency for lack of communicable disease screening and missing out-of-state background check.
Caregiver DNamed in deficiencies for missing department-approved training in fire safety, first aid, choking, and resident rights.
Administrator AInterviewed multiple times regarding missing documentation and deficiencies.
Wellness Director BInterviewed regarding Resident 1's tuberculosis screening.

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