Inspection Report Summary
The most recent inspection on May 12, 2025, identified deficiencies related to regulatory compliance and included a complaint investigation. Earlier inspections showed a pattern of issues involving medication administration, notification to residents’ legal representatives, employee qualifications, and required staff training. Inspectors cited delays in administering prescribed medication and failures to notify legal representatives of significant changes or allegations, as well as employment of a caregiver without proper approval. Several complaint investigations were conducted, with some substantiated cases involving medication misappropriation and medication delays, while most complaints were unsubstantiated. The facility’s deficiencies have appeared intermittently over time without a clear pattern of consistent improvement or worsening.
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/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
20 residents
Based on a May 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 12, 2025
Visit Reason
A Standard Survey and Complaint Investigation were conducted to determine if Wyndemere Aspen House was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related as it included a Complaint Investigation. Specific substantiation status is not stated.
Findings
The Department issued a Statement of Deficiency (SOD #6ZTV11) for violations of Wisconsin Statutes and Administrative Code related to the operation of the facility, establishing grounds for regulatory action and an order to comply with requirements.
Report Facts
Days to achieve compliance: 45
Appeal filing period: 10
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter. |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 2
Date: May 7, 2025
Visit Reason
Surveyors conducted a standard survey and complaint investigation at Wyndemere Aspen House due to a complaint alleging concerns with medication administration.
Complaint Details
The complaint was substantiated. It alleged concerns with medication administration, specifically a delay in administering prescribed antibiotics to Resident 1.
Findings
Two deficiencies were identified: failure to immediately notify a resident's legal representative of a significant change in condition and hospital transfer, and failure to administer prescribed medication (cephalexin) in a timely manner, resulting in a delay of two and a half days before the first dose was given.
Deficiencies (2)
Failure to immediately notify Resident 1's legal representative of a change in condition and hospital transfer on 11/16/2024.
Resident 1 did not receive prescribed cephalexin medication for acute UTI until two and a half days after physician's order dated 11/16/2024.
Report Facts
Days delay in medication administration: 2.5
Census: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Coordinator A | Verified lack of notification to Resident 1's legal representative and confirmed medication delay details. |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 0
Date: May 8, 2024
Visit Reason
Surveyor conducted 2 complaint investigations and a verification visit at Wyndemere Aspen House to investigate complaints and verify correction of previous deficiencies.
Complaint Details
Two complaints were investigated and found to be unsubstantiated.
Findings
The complaints were unsubstantiated and all previous deficient practices were corrected. No deficient practices were identified during the visit.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 4
Date: Oct 2, 2023
Visit Reason
The surveyor conducted a standard licensing survey and 4 complaint investigations, including one substantiated complaint regarding medication misappropriation.
Complaint Details
One complaint was substantiated regarding stolen resident medications (16 tablets of Vicodin). Three complaints were unsubstantiated.
Findings
Four violations of Chapter DHS 83 were issued, including failure to investigate and report misappropriation of medication, failure to notify a resident's legal representative of the misappropriation allegation, employment of a caregiver with a disqualifying conviction without department approval, and failure to ensure required employee training in first aid and choking.
Deficiencies (4)
Failure to investigate and report an incident of misappropriation of 16 tablets of Vicodin stolen from the facility.
Failure to notify Resident 1's legal representative of the allegation of misappropriation of property within required timeframe.
Employment of Caregiver E despite a conviction for felony child neglect without department rehabilitation approval.
Failure to ensure Caregiver D completed required training in first aid and choking within 90 days of hire.
Report Facts
Number of violations issued: 4
Number of tablets stolen: 16
Census: 19
Caregiver E hire date: Sep 2, 2022
Caregiver E conviction date: Dec 18, 2020
Caregiver D hire date: Jun 11, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver E | Caregiver | Employed despite felony child neglect conviction without department rehabilitation approval. |
| Caregiver D | Caregiver | Did not complete required training in first aid and choking. |
| Wellness Director A | Interviewed regarding missing medication incident and employee training deficiencies. | |
| Regional Director B | Interviewed by phone regarding missing medication incident and investigation. | |
| Former Manager C | Responsible for investigation of missing medication but did not conduct or document it; no longer employed. |
Notice
Deficiencies: 0
Date: Oct 2, 2023
Visit Reason
The document serves as a Notice of Violation and Order to Comply following a Standard Survey and Complaint Investigation conducted to determine if Wyndemere Aspen House 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 the issuance of Statement of Deficiency #9HX511 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: 19
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
The surveyor investigated one complaint and reviewed one self-report at Wyndemere Aspen House.
Complaint Details
One complaint was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were identified as a result of the survey.
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