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Whitewater Health Services

525 Bluff Avenue, St Charles, MN 55972 · For profit - Corporation · 45 certified beds · (507) 932-3283 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Jun 20251 immediate-jeopardy citation$16,452 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (23% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Jun 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,452 in federal fines (most recent 2024-08-06)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
403 W 4th St · (507) 932-3810 · Call to confirm hours
Pharmacy
401 W 4th St · (507) 932-3160 · Call to confirm hours
Grocery
1337 Whitewater Ave · (507) 932-3760 · Call to confirm hours
Park
1201 Whispering Hills Dr · Typically dawn to dusk

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.5%18.2%15.4%typical
Long-stay residents who lose too much weight4.3%4.1%5.4%better
Long-stay residents with a catheter left in their bladder14.4%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.2%2.6%2.0%better
Long-stay residents with depressive symptoms2.7%4.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.0%4.0%3.3%worse
Long-stay residents whose ability to walk worsened20.2%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.4%12.5%18.9%better
Long-stay residents with pressure ulcers0.9%5.2%4.7%better
Long-stay residents with worsening bladder/bowel control23.0%24.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table9.1%17.1%17.1%better
Short-stay residents who newly got an antipsychotic medication1.3%1.9%1.4%typical
Short-stay residents given the seasonal flu vaccine61.9%82.7%79.4%worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

57.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.8%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
0.21U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 33% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF57.8%CMS range 43.7–73.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 7.0–15.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.821.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.00
RN hours/ resident / day
0.67
LPN hours/ resident / day
1.85
Aide hours/ resident / day
3.52
Total nurse hours/ resident / day
0.58
RN hoursweekends
22.7%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 45 beds and averages 31.5 residents a day — about 70% occupied, or roughly 14 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.00 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.26 hrs/resident/day on weekends vs 3.63 on weekdays — 10% thinner on weekends. RN hours go from 1.17 to 0.58 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 23% is below the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2026-07-02)
5
at the previous standard inspection (2025-05-14)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · J2024-08-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify, comprehensively assess, implement interventions, and provide timely physician notification for a sudden change in condition for 1 of 3 residents (R1) reviewed for change in condition. This resulted in an immediate jeopardy (IJ) when R1 became unresponsive causing a delay in hospitalization. Immediate Jeopardy (IJ) began on [DATE] when the facility did not complete comprehensive assessments and communicate sudden change of condition to the physician when R1 became unresponsive and remained unresponsive for at least seven (7) hours before the ambulance arrived. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 4:58 p.m. The immediacy of the IJ was removed on [DATE] at 12:43 p.m. but noncompliance remained at the lower scope and severity level 2 (D), which indicated no actual harm with potential for more than minimal harm that is not IJ. Findings include: R1's hospital after visit summary (AVS) [DATE],…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-07-02 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to maintain a clean, homelike environment when it was identified a refrigerator used to supply resident supplement drinks were not cleaned. In addition, during dining, meals were served on trays. This failure had an opportunity to affect all residents who received supplemental drinks and who received meals in the dining rooms.Findings include:During the initial kitchen tour on 6/29/2026 at 10:35 a.m., with cook (C)-A verified the refrigerator in the dining room where the residents house supplement is kept had a large amount of ice built up on the top freezer part with an unknown item within the ice. C-A indicated uncertain who was in charge to clean, monitor or who to report it to. During an interview on 7/01/2026 at 11:45 a.m., maintenance-B said when staff have things that need to be looked at, they are to place a ticket in the TELS. Maintenance-B indicated the TELS is where we would get notified of something needing fixed.During an observation and interview on 7/01/2026 5:50 p.m., administrator verified the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · E2026-07-02 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to maintain equipment in good working order for 1 kitchen dishwashing system and surrounding area.Findings include:During the initial kitchen tour on 6/29/2026 at 10:35 a.m., [NAME] (C)-A identified dishwater and off to the left underneath counter a metal device with a large amount of water flowing from it. surrounding the device the tile floor was buckled and the trim around the perimeter of the wall was peeled back. C-A indicated maintenance has known of the water leak for about a month.During an observation and interview on 7/01/2026 at 11:45 a.m., maintenance (M)-B was asked to review the leak in the kitchen. After walking in the kitchen, M-B quickly went to the area and turned the water off. M-B was made aware on 6/30/26 from M-A. M-B indicated staff are to use the TELS system (a systems to give updates to maintenance of things needing attention). He reviewed TELS and verified staff did not report. M-B confirmed the damage was not new and should have been reported sooner. M-B indicated a plumber will be…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-07-02 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to maintain dignity when it was identified a brace was not cleaned regularly for 1 of 1 resident (R1) reviewed for dignity.Findings include:R1's quarterly Minimum Data Set (MDS) assessment, dated 4/11/26, indicated R1 was not cognitively impaired. In addition, needed partial to moderate assistance to dress upper body.R1's care plan includes a focus for ADL (activity of daily living) assist of one staff for dressing, related to recurrent dislocation of right shoulder, and at risk for loss of range of motion and to apply device (specify-immobilizer) per physician orders.R1's orders include, the immobilizer should be removed twice daily, including for showers, to check underlying skin to ensure no rubbing. The immobilizer should be on at all times, otherwise.During an observation on 6/29/2026 at 4:57 p.m. R1 had a brace on right shoulder which wrapped around his trunk. The brace is dirty and or stained.During an observation and interview on 7/01/2026 at 12:03 p.m., registered nurse (RN)-A indicated there is an order…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-07-02 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review facility failed to notify the physician with a change of condition for 1 of 1 resident (R31) reviewed for discharge.Findings include:R31's Quarterly Minimum Data Set (MDS) assessment, dated 5/7/26 includes intact cognition with no mood or behaviors. R31's focus care plan indicates residents shows potential for discharge, will be discharged to home when clinical and rehabilitation goals are met.R31's physician encounter visit dated 3/24/26, indicates Nursing home discharge. Discharge preparation time spent with patient 40 minutes including the following tasks, reviewed the electronic medical record, updating epic problem list, medication,. time electronically signed 4:35 p.m., with another date and time of 3/27/26 at 2:25 p.m.R31's patient message dated 3/24/26 at 4:36 p.m., indicates discharge recommendation faxed to facility on 3/24/26 at 4:50 p.m.R31's record lacked communication with the provider R31 remained in the facility after signed discharged orders were received.R31's physician became aware R31 remained in the facility on 4/15/26 when…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-07-02 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to appropriately assess and reevaluate interventions discussed in a timely manner to help prevent future falls for 1 of 4 residents (R1) reviewed for accidents who had 23 falls.Findings include:R1 admitted to the facility 1/20/2026R1's care plan focus area dated 1/21/26 indicated R1 is at increased risk for actual fall related to history of (h/o) falls, impaired decision making, failure to recognize physical limitations, impaired safety awareness, and attempts to self-transfer. R1's goal is to minimize risk of falls. Original interventions included; ensure R1 is wearing appropriate footwear (gripper socks or shoes), have commonly used articles within easy reach, provide assist to transfer and ambulate as needed, reinforce wheelchair safety as needed such as locking brakes, report development of pain, bruises, change in mental status, ADL function, appetite, or neurological status post fall, and therapy to work on transfer, walking, strengthen.R1's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-07-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow care plan interventions requested by the resident for 1 of 1 resident (R5) reviewed for bladder incontinence.Findings include:R5 Quarterly Minimum Data Set (MDS) assessment dated [DATE], included intact cognition, no mood or behaviors, frequently incontinent with no toileting program.R5's care plan focus area for urinary incontinence related to functional incontinence with an intervention of a toileting plan: check and change every 2 hours starting in the am, between meals and at 10:30 p.m., then at 2-3 a.m., last check at 5a.m.During an observation and interview on 6/29/2026 at 3:52 p.m., R5 lying in bed when asked about going to the bathroom, R5 said, she does not make it to the restroom all the time. Staff are to check and change her or go to the bathroom every two hours. R5 continues and said it does not happen all the time and added some staff are better than others. R5's care conference summary dated 4/2/26 reads resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-07-02 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain a medical record that was complete, accurate and readily accessible for 1 of 1 resident (R29) reviewed for death record.Findings include:R29's Hospital Discharge summary revealed being discharged to the nursing home on [DATE] in stable condition.R29's Provider Orders for Life-Sustaining Treatment (POLST) dated [DATE] reads attempt CPR.R29's death record reads date of death [DATE]R29's Minimum Data Set assessment dated [DATE] indicates death in facility.R29's progress lacked documentation of R29 death in the facility or what had happened.R29's encounter date [DATE] at 9:58 a.m., received call R29 passed away this morning, CPR started, 911 called.State agency asked for R29's incident report and or medical record to include items that would have anything to do with the day of R29's death. Upon follow of request, it was brought to the attention there was no incident report or progress note of what occurred the day of R29's death.During an interview…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Dcited before2026-04-16 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to develop a baseline care plan to ensure enhanced barrier precaution (EBP) needs were identified and addressed for 2 of 3 residents (R1 and R2) reviewed for indwelling catheters.Findings include:R1R1's admission record dated 3/31/26, indicated R1 had benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms. R1's order summary report dated 3/31/26, indicated R1 had an indwelling urinary catheter.R1's care plan dated 4/14/26, indicated R1 had an indwelling foley catheter. R1's care plan failed to include R1's need for EBPs as well as interventions related to this need.R1's medical record lacked evidence to ensure staff were knowledgeable in R1's need for EBPs. During an observation on 4/15/26 at 10:12 a.m., R1 was observed sleeping in his recliner. The door to the room was open and R1's foley catheter leg bag was visible attached to R1's leg. R1 did not have any signage or supplies for EBPs at his room door.R2R2's admission record dated 3/27/26, indicated R2 had benign prostatic hyperplasia with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-16 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the required nurse staffing information was posted daily. This had the potential to affect all 33 residents residing in the facility and/or visitors who may wish to see the information.Findings include:During an observation on 4/15/26 at 9:59 a.m., the facility nurse staffing information was not observed on the administrator's office door.During an observation on 4/15/26 at 10:16 a.m., the primary areas, hallways, and entrance of the facility was observed, and no facility nurse staffing information was observed.On 4/15/26 at 11:23 a.m., the administrator stated she was responsible for posting nurse staffing information and it would have been located on her office door, but it was not because she had not printed or posted it. It was expected that the nurse staffing information is posted seven days a week.The facility policy titled Nurse Staffing Postage Information revised 10/13/22, indicated staffing information would be readily available in a readable format to residents and visitors at any given time…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and document review, the facility failed to ensure staff consistently implemented enhanced barrier precautions (EBP) in accordance with Centers for Disease Control (CDC) guidelines to reduce the risk of infection spread for 1 of 3 residents (R1) reviewed for an indwelling catheter.Findings include:R1's admission record dated 3/31/26, indicated R1 had benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms.R1's order summary report dated 3/31/26, indicated R1 had an indwelling urinary catheter.R1's care plan dated 4/14/26, indicated R1 had an indwelling foley catheter. R1's medical record lacked evidence to ensure staff were knowledgeable in R1's need for EBPs.During an observation on 4/15/26 at 10:12 a.m., R1 was observed sleeping in his recliner. The door to the room was open and R1's foley catheter leg bag was visible attached to R1's leg. R1 did not have any signage or supplies for EBPs at his door.During an observation on 4/15/26 at 11:40 a.m., physical therapist (PT)-A was in R1's bathroom assisting him out of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · E2025-06-16 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation of property for five of eight residents (R2, R4, R5, R6, R8) reviewed when multiple nursing staff took medication belonging to one resident to administer to another resident when their medication supply ran out. Findings include: During an observation on 6/11/25 at 9:53 a.m. R2's levothyroxine 50 micrograms (mcg) medication card had doses, 30 through 17 removed and tablets one and two were removed. There was nothing written on the doses one and two. R4's potassium chloride 20 milliequivalent (mEq) medication card had doses 30 through five removed and doses one and two were removed. Written on the medication card was 5/18 for resident J.J (R7). R5's glipizide five milligram (mg) medication card had doses 30 through seven removed and dose one was removed at the bottom of the medication card and was initialed LM. R5's clozapine 100 mg medication card had doses 30 through 25 removed and doses…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-16 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that alleged violations involving misappropriation of resident medications were reported to the state agency not later than 24 hours of the incidents for five of eight residents (R2, R4, R5, R6, and R8). The facility knew about the misappropriation of resident medications on 6/9/25 and did not report to the state agency. Findings include: During an observation on 6/11/25 at 9:53 a.m. R2's levothyroxine 50 micrograms (mcg) medication card had doses, 30 through 17 removed and tablets one and two were removed. There was nothing written on the doses one and two. R4's potassium chloride 20 milliequivalent (mEq) medication card had doses 30 through five removed and doses one and two were removed. Written on the medication card was 5/18 for resident J.J (R7). R5's glipizide five milligram (mg) medication card had doses 30 through seven removed and dose one was removed at the bottom of the medication card and was initialed LM. R5's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-16 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate allegations of misappropriation of resident medications for five of eight residents (R2, R4, R5, R6, and R8) when the facility found out about these allegations on 6/9/25, placed DON-A on administrative leave pending an investigation. Findings include: During an observation on 6/11/25 at 9:53 a.m. R2's levothyroxine 50 micrograms (mcg) medication card had doses, 30 through 17 removed and tablets one and two were removed. There was nothing written on the doses one and two. R4's potassium chloride 20 milliequivalent (mEq) medication card had doses 30 through five removed and doses one and two were removed. Written on the medication card was 5/18 for resident J.J (R7). R5's glipizide five milligram (mg) medication card had doses 30 through seven removed and dose one was removed at the bottom of the medication card and was initialed LM. R5's clozapine 100 mg medication card had doses 30 through 25 removed and doses five through one…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-16 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure residents medications were ordered in advanced and medications were administered as prescribed for five of eight residents (R2, R4, R5, R6, R8) reviewed when residents were administered other resident's medications when their supply ran out. Findings include: During an observation on 6/11/25 at 9:53 a.m. R2's levothyroxine 50 micrograms (mcg) medication card had doses, 30 through 17 removed and tablets one and two were removed. There was nothing written on the doses one and two. R4's potassium chloride 20 milliequivalent (mEq) medication card had doses 30 through five removed and doses one and two were removed. Written on the medication card was 5/18 for resident J.J (R7). R5's glipizide five milligram (mg) medication card had doses 30 through seven removed and dose one was removed at the bottom of the medication card and was initialed LM. R5's clozapine 100 mg medication card had doses 30 through…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a self-administration of medication (SAM) assessment was completed for 1 of 1 resident's (R16) reviewed for medication administration. Findings include: R16's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R16 was cognitively intact. R16's provider orders, included an order for Nystatin antifungal powder to both breasts and groin folds every 12 hours as needed . During observation on 5/14/25 at 7:17 a.m., registered nurse (RN)-A dispensed antifungal powder in a medication cup, walked to R16's room, and handed the medication cup to the director of nursing (DON) who was already in the room. The DON then placed the cup of powder on R16's bedside table and left the room. The DON stated R16 was getting ready for the day and would apply the powder herself when she is ready. During interview on 5/14/25 at 10:55 a.m., RN-A stated she did not think any current residents had a SAM assessment. RN-A stated a SAM assessment…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-14 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to complete and implement a baseline care plan within 48 hours of admission for 1 of 2 residents (R125) reviewed for new admissions. Findings include: R125's face sheet, indicated R125 admitted on [DATE]; diagnosis include, heart failure, respiratory disease, right lower leg pressure ulcer (reduce blood pressure to body area, leading to skin and tissue damage), left lower leg pressure ulcer, right hip pressure ulcer, perineum (area of sensitive skin between genitals and anus) wound, spinal vertebrae pain, lumbar pain, adult failure to thrive and a new diagnosis of urinary retention requiring a urinary catheter to drain bladder. R125's resident admission Minimum Data Set (MDS) assessment was not completed at time of survey. R125's cognitive function was intact. R125's a baseline care plan had not been initiated at time of survey; pain management treatment and goals had not been assessed. During interview on 5/12/25 at 10:39 a.m., R125 stated she has been…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to identify, treat, follow up on pain and offer non-pharmacological interventions for 1 of 1 resident (R125) reviewed for pain management who was newly admitted . Findings include: R125's resident admission Minimum Data Set (MDS) assessment was not completed at time of survey. R125's had intact cognitive. R125 was admitted on [DATE] following a hospital stay, R125's diagnosis include, heart failure, respiratory disease, right lower leg pressure ulcer (reduce blood pressure to body area, leading to skin and tissue damage), left lower leg pressure ulcer, right hip pressure ulcer, perineum (area of sensitive skin between genitals and anus) wound, spinal vertebrae pain, lumbar pain, adult failure to thrive and a new diagnosis of urinary retention requiring a urinary catheter to drain bladder. R125's record lacked a baseline care plan. R125's pain management, treatment and goals was not assessed upon admission. R125's orders included Lyrica…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff followed proper infection control practices for 1 of 1 resident (R11) reviewed for urinary catheter. Staff failed to ensure a mechanical transfer lift was cleaned and disinfected after resident use for 1 of 1 resident (R125) observed for infection control. Furthermore, staff failed to ensure proper personal protective equipment (PPE) was used for 2 of 2 residents (R125, R126) observed for proper PPE. Findings include: R11 R11's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R11 was cognitively intact with no behaviors, had range of motion limitations to both lower extremities, and was dependent on staff for lower body cares, bed mobility, and transfers. It also indicated R11 had a urinary catheter and colostomy, history of spina bifida (genetic neurologic condition), history of UTI, paraplegia (paralysis of lower extremities due to disorder of the nerves). R11's physician orders indicated R11 required…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure proper hand hygiene after meal service and during personal cares for 3 of 3 resident (R1, R2, R4) observed for hand hygiene. Finding include: R1's quarterly minimum data set (MDS) dated [DATE], identified R1 was understood and understands both verbal and nonverbal expressions, had moderate cognitive impairment, and was dependent on staff for assistance with most to all dressing and grooming activities. R1's skin care plan dated 9/11/23, identified R1 had ongoing pressure ulcers and skin concerns, with goals to heal without complications. Intervention included report evidence of infections. R1's activities of daily living (ADL) care plan dated 7/10/23, indicated self-care deficit as evidenced by inability to complete independently related to cerebral vascular accident (CVA) and essential tremors. During an observation on 6/12/24 at 7:34 a.m., nursing assistant (NA)-A and NA-B assisted R1 with incontinent care before transferring…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-05-14 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure the facility's state survey results were kept in a location readily accessible to all residents and/or visitors. This had the potential to affect all 22 residents and/or visitors who could wish to review the information. Findings include: R16's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R16 had intact cognition. During resident council meeting on 5/12/25 at 10:50 a.m., R16 (resident council president) stated she did not know the state survey results were available to be read and confirmed she would be interested in seeing them. During observation and interview on 5/12/25 at 11:21 a.m., social worker (SW) said the facility had a survey binder and was unsure where the binder was located. SW walked out to main atrium and could not readily find the survey results binder. During observation and interview on 5/12/25 at 12:00 p.m., assistant director of nursing (ADON) and corporate vice president of success (VP)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$16,452 in federal fines across 1 penalty.

  • $16,452 — penalty dated 2024-08-06

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to NORTH SHORE HEALTHCARE — 59 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.7-0.7 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 4 of 53.4+0.6 vs chain
Quality measures 3 of 52.5+0.5 vs chain
The other 58 homes this chain runs (chain average 2.7★, per CMS)
1 of 5Elroy Health ServicesElroy, WI 1 of 5Florence Health ServicesFlorence, WI 1 of 5Hopkins Restorative Care CenterHopkins, MN 1 of 5La Crescent Health ServicesLa Crescent, MN 1 of 5Little Chute Health ServicesLittle Chute, WI 1 of 5Minot Health And Rehab, LLCMinot, ND 1 of 5Plymouth Health ServicesPlymouth, WI 1 of 5Rochester Restorative Care CenterRochester, MN 1 of 5Sheboygan Progressive Health ServicesSheboygan, WI 1 of 5Williams Bay Health ServicesWilliams Bay, WI 1 of 5Wisconsin Rapids Health ServicesWisconsin Rapids, WI 2 of 5Birch Hill Health ServicesShawano, WI 2 of 5Colonial Health ServicesColby, WI 2 of 5Evergreen Health ServicesShawano, WI 2 of 5Green Bay Health ServicesGreen Bay, WI 2 of 5Heritage Health ServicesPort Washington, WI 2 of 5Lake Country Health ServicesOconomowoc, WI 2 of 5Lancaster Health ServicesLancaster, WI 2 of 5Maple Ridge Health ServicesMilwaukee, WI 2 of 5Menomonee Falls Health ServicesMenomonee Falls, WI 2 of 5Mineral Point Health ServicesMineral Point, WI 2 of 5Soldiers Grove Health ServicesSoldiers Grove, WI 2 of 5Stevens Point Health ServicesStevens Point, WI 2 of 5Sunrise Health ServicesMilwaukee, WI 2 of 5Three Oaks Health ServicesMarshfield, WI 2 of 5Tomahawk Health ServicesTomahawk, WI 2 of 5Willowcrest Health ServicesSouth Milwaukee, WI 3 of 5Cedarburg Health ServicesCedarburg, WI 3 of 5Court Manor Health ServicesAshland, WI 3 of 5Hayward Health ServicesHayward, WI 3 of 5Homestead Health ServicesNew Holstein, WI 3 of 5Mercy Health ServicesMilwaukee, WI 3 of 5Morningside Health ServicesSheboygan, WI 3 of 5Oakwood Health ServicesAltoona, WI 3 of 5Randolph Health ServicesRandolph, WI 3 of 5Rib Lake Health ServicesRib Lake, WI 3 of 5River's Bend Health ServicesManitowoc, WI 3 of 5Riverview Health ServicesTomahawk, WI 3 of 5Sheboygan Health ServicesSheboygan, WI 3 of 5St Francis Health ServicesSaint Francis, WI

Showing 40 of 58; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
NSHC WISCONSIN LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 05/14/2025
BAUMANN, TROYIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2016
HOEHN, JEFFREYIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2016
CIBC BANK USAOrganization5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 12/31/2024
CLIFTONLARSONALLEN LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2025
CONTINUUM THERAPY PARTNERS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
NORTH SHORE HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2017
NSH REHAB LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
WIPFLI LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2025
BELONGIA, CHRISTINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2019
GEE, DARRENIndividualOPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 11/30/2021
GIMLIN, LINDSAYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/08/2025
GREER, LAURENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/29/2023
PATZER, COLLEENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/14/2023
PONTON, LILIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
PURTELL, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2018
GPH ST. CHARLES LLCOrganizationADP OF THE SNFsince 12/01/2016

CMS files one row per role, so the 38 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$3.5M
Net patient revenuemost recent cost report
-15.4%
Operating marginrevenue minus expenses
$176K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 60%Medicare 7%Other / private 33%

This home reported $176K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$352per resident / day
operating cost
$10,715per month
≈ monthly operating cost
$305per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.

Typical monthly cost in Minnesota
$10,646/mo
Nursing home (semi-private)
$13,870/mo
Nursing home (private)
$6,573/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245270. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-02, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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