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Oakwood Health Services

2512 New Pine Dr, Altoona, WI 54720 · For profit - Limited Liability company · 80 certified beds · (715) 833-0400 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Feb 20251 immediate-jeopardy citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$36,552 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — 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
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $36,552 in federal fines (most recent 2025-02-20)

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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1200 Oakleaf Way · (715) 832-1400 · Call to confirm hours
Pharmacy
1819 S Hastings Way · (715) 834-3121 · Call to confirm hours
Grocery
2855 Woodman Drive, Altoona, WI, 54720
Park
2300 Spooner Ave · (715) 839-5188 · Typically dawn to dusk
Place of worship

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 1 of 5
Short-stay residentsrehab / post-hospital 5 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 held steady at 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 increased22.1%16.1%15.4%worse
Long-stay residents who lose too much weight4.9%5.1%5.4%typical
Long-stay residents with a catheter left in their bladder2.5%2.1%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection4.8%2.7%2.0%worse
Long-stay residents with depressive symptoms14.9%5.7%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.8%3.3%3.3%worse
Long-stay residents whose ability to walk worsened32.0%18.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication25.2%16.9%18.9%worse
Long-stay residents given the seasonal flu vaccine95.2%95.0%95.3%typical
Long-stay residents with pressure ulcers3.6%5.0%4.7%better
Long-stay residents with worsening bladder/bowel control34.8%24.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table12.2%15.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine66.1%82.2%79.4%worse
Short-stay residents rehospitalized after admission9.4%23.1%22.6%better
Short-stay residents with an outpatient ER visit23.0%15.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.871.661.67worse
Long-stay outpatient ER visits per 1,000 resident days2.122.291.80worse

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.

53.8% 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 128 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.8%U.S. median 51.5%
Got home and stayed home
8.6%U.S. median 10.7%
Went back to hospital
58.6%U.S. median 56.6%
Met the expected recovery
0.35U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 58.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 29 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 SNF53.8%CMS range 45.3–62.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.6%CMS range 6.1–11.610.7%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 discharge58.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge44.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge44.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this 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 stay5.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.1%CMS range 5.3–14.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.811.02Oct 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

1.03
RN hours/ resident / day
0.73
LPN hours/ resident / day
2.33
Aide hours/ resident / day
4.08
Total nurse hours/ resident / day
0.67
RN hoursweekends
32.1%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 59.0 residents a day — about 74% occupied, or roughly 21 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 4.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.03 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.33 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 3.55 hrs/resident/day on weekends vs 4.30 on weekdays — 17% thinner on weekends. RN hours go from 1.17 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% 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

9
deficiencies at the latest standard inspection (2026-03-11)
4
at the previous standard inspection (2024-12-18)

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.

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · J2025-02-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 protect the resident's right to be free from mental abuse by staff. This affected 1 of 3 residents (R1) reviewed for mental abuse. Staff held R1 down and forced R1 to be catherized against her wishes. As a result, R1 experienced severe trauma and fear, stating she did not feel safe in the facility and requested to be removed from the facility. The facility's failure to ensure R1 was free from abuse created a finding of immediate jeopardy that began on 2/01/25. Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and [NAME] President of Success (VPS) G were notified of the immediate jeopardy on 2/12/25 at 3:32 PM. The immediate jeopardy was removed 02/01/25 and corrected on 02/03/25. Based on this determination, this citation is being cited as past noncompliance. This is evidenced by: Surveyor requested and received the facility policy titled Abuse, Neglect and Exploitation dated 7/15/2022. The facility policy states in part, Policy: It is…

    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 · Past Non-Compliance
  • Immediate jeopardy · J2024-08-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 did not ensure each resident receives cares consistent with professional standards of practice to prevent pressure injuries (PIs) for 2 of 4 sampled residents (R)1 and R3. On admission 5/20/24, staff identified R1 had a suspected deep tissue injury (DTI) from the coccyx to the peri area. Physician, Director of Nursing, or wound nurse were not notified of this suspected DTI. No care plan or interventions were put in place for the pressure injury. Pressure injury assessments were not completed after the identification of the DTI on 5/20/24. As a result, R1 developed an unstageable pressure injury and sepsis. R1 required hospitalization and surgical debridement of the PI. The PI was staged as a stage 4 pressure injury. The facility's failure to implement pressure injury interventions and assess R1's pressure injury, created a finding of immediate jeopardy that began on 05/27/24. Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and…

    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 · E2026-03-11 · tag F0697 — failed to manage pain — pattern
    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 interview and record review, the facility did not ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 7 of 7 residents reviewed (R7, R11, R39, R41, R44, R70, and R74).There was no documentation of non-pharmacological interventions for pain for R7, R11, R39, R41, R44, R70, and R74.Facility ran out of pain medications for R44.Findings include: Facility Policy titled, Pain Management, last revised on 08/09/2022, reads in part: The facility must ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.Non-pharmacological interventions will include but are not limited to: Environmental comfort measures.loosening restrictive clothing.cold compress, warm shower/bath, massage.music,…

    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 · D2026-03-11 · 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 observations, interviews, and record review, the facility did not determine safe self-administration of medications for 1 out of 17 residents (R) reviewed (R39).Surveyor observed R39 to have a cup of medications on the bedside table sitting in front of her while she was sleeping in her chair. R39 did not have an assessment for self-administration of medications, and R39 did not have a physician's order for self-administration.This is evidenced by: The facility's policy titled, Medication Administration, Section 7.3, Self-Administration by Resident dated 1/26, states in part, . Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the medications are appropriate and safe for self-administration. The facility's policy titled, Medication Administration, Section 7.1, General Guidelines dated 1/26, states in part, 13. Explain to resident the type of medication being administered and the procedure. R39 was admitted to the facility on [DATE] with diagnoses…

    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 · D2026-03-11 · tag F0572 — isolated
    Give residents a notice of rights, rules, services and charges.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not ensure 1 resident (R39) of 5 medication administration observations was fully informed of but not limited to; resident rights and required medication information with options as requested by R39 prior to administering R39's medications during medication administration. Registered Nurse (RN) N did not provide information as requested by R39 before administering questionable medications that R39 had concern for.Findings include: Facility policy titled Medication Administration, last revised 01/26, stated in part, .medication administration #13. Explain to resident the type of medication being administered and the procedure. On 03/11/2026 at 7:14 AM, Surveyor observed RN N entering R39's room. RN N placed medications on the table. R39 asked RN N where R39's applesauce is as R39 takes medications with applesauce. RN N reported that kitchen did not have applesauce, but RN N brought chocolate pudding instead. R39 reported that R39 did not want chocolate pudding. R39 complained of not wanting to take medications because R39 does…

    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 · D2026-03-11 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility did not ensure employees were screened for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed.The facility did not ensure their abuse policy was implemented when one employee's background information disclosure (BID) was not obtained before employee started working at facility. (LPN M).Findings include:The facility policy, titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, last revised 01/26, stated in part, .Employee screening and training: a. Before new employees are permitted to work with residents' board registrations and certifications regarding prospective employees' backgrounds will be checked. d. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks.On 03/11/26 at 10:14 AM, Surveyor reviewed 8 random staff Background Information Disclosures (BID).Licensed Practical Nurse (LPN) M was hired on 01/29/26. Surveyor found BID dated…

    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 · D2026-03-11 · 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 observations, interviews, and record reviews, the facility did not ensure that a resident receives appropriate treatment and services to prevent urinary tract infections to the extent possible for 1 of 3 reviewed. (R20)-R20 has a suprapubic catheter, and it was not kept below the bladder level.The facility policy titled, Catheter Care, dated 03/15/23, indicates drainage bags are to be located below the level of the bladder to discourage backflow of urine. There is no mention of proper tubing placement. R20 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, retention of urine, dysfunction of bladder, cystostomy, and history of MRSA. R20's Minimum Data Set (MDS), dated [DATE], indicated that R20 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating that R20 had moderately impaired cognition. R20's care plan dated 08/15/25 notes, Use of indwelling urinary catheter suprapubic needed due to neurogenic bladder secondary to MS. R20 is dependent on staff…

    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 · D2026-03-11 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services 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 interview and record review, the facility did not ensure ongoing assessment of the resident's condition and monitoring for complications before dialysis treatments for 2 of 2 residents reviewed (R1, R6).R1 and R6 did not have pre-dialysis weights performed. Previous dialysis day's weights utilized for majority of assessments.Findings include:Facility Policy titled, Hemodialysis, last revised on 09/10/23, reads in part: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments.nutritional/fluid management including documentation of weights.Example 1R1 was admitted to the facility on [DATE].Most recent…

    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 · D2026-03-11 · tag F0755 — failed to provide safe pharmacy services — isolated
    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

    Based on observation, record review, and interview, the facility did not ensure drugs and biologicals were labeled with an open date/expiration date in accordance with currently accepted professional principles for 1 of 1 resident (R) (R11).Facility did not have an open/expiration date label on R11's opened bottle of Roxanol.Findings include:On 03/10/2026 at 9:38 AM, Surveyor observed medication cart on Aspen unit. Surveyor observed in narcotic box R11's Roxanol 20mg/ml liquid bottle. Surveyor observed R11's Roxanol liquid bottle opened with no open date label. Surveyor asked Medication Aide (MA) E if it is normal process for liquid controlled substances to not be labeled once opened. MA E reported that R11's Roxanol bottle should have been labeled with an open date label. Surveyor asked MA E when MA E's last dose was given. MA E reported after looking at R11's Medication Administration Record (MAR), R11 received Roxanol second dose today on 03/10/26 at 3:00 AM. On 03/10/2026 at 3:52 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B for expectation of open…

    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 · D2026-03-11 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    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 observations, interviews, and record review, the facility did not provide special eating equipment and utensils for residents who need them when consuming meals for 1 of 17 residents reviewed. (R14)R14 requires the use of a divided plate, built up utensils, and a nosey cup. R14 was not provided with built up utensils or the nosey cup during lunch.R14 was admitted on [DATE] with diagnoses that include dementia, stroke, abnormal posture, dysphagia, and diabetes. R14's most recent Brief Interview of Mental Status (BIMS) score was 0 of 15 which indicates R14 had severe cognitive impairment. R14's care plan with a revision date of 01/27/26 notes R14 is at risk for nutritional status due to diabetes and dementia. Interventions include set up assistance and to encourage to use divided plates, nosey cup, built-up utensils and clothing protector. On 03/09/26 at 12:17 PM, Surveyor observed R14 in the dining room using a divided plate, and regular cup and utensils. Certified Nursing Assistant (CNA) K was feeding…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-11 · 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 did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 out of 3 residents (R) observed for wound care (R70) Staff did not change gloves or perform hand hygiene during observation of wound care.R70's wound suction tubing was unplugged, and the open end of suction vacuum tubing was touching the floor. Staff did not clean or disinfect the tubing end prior to reconnecting to clean wound suction dressing. Findings include:The facility policy titled, Personal Protective Equipment, revised 3/17/2023, states in part, 4. Indications/considerations for PPE use: a. Gloves:. iv. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn.The Center for Disease Control (CDC) wound care…

    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 before2025-06-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    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 record review, observation and interview, the facility did not ensure the residents remain free of possible accidental hazards. Facility did not ensure staff were applying the correct size Hoyer (mechanical full body lift) sling to prevent accidents for 1 of 10 residents (R) reviewed. (R3). Certified Nursing Assistants (CNA) used a size large instead of the care planned size medium Hoyer sling for R3. This occurred after nursing staff received education and skill checks within the last month. Findings include: Facility policy titled, NSG-Save Resident Handling and Transfers, dated 08/05/22, states: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Resident lifting and transferring will be performed according to the resident's individual plan of care. R3…

    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
Show the remaining 13 citations
  • Potential for harm · Fcited before2024-12-18 · tag F0880 — failed to prevent and control infections — widespread
    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 did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, or a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 39 residents in the facility. The facility did not have an adequate surveillance in place for tracking and monitoring infection and communicable disease for staff and residents. The facility did not ensure proper fitting N95 mask for staff with facial hair of a full beard. Facility staff did not dispose of contaminated Personal Protective Equipment (PPE) before exiting COVID positive rooms. The facility did not initiate Enhanced Barrier Precautions (EBP) upon R91's admission to the facility with an indwelling urinary catheter. R35 was placed on contact precautions after having one incident of vomiting. Staff did not…

    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 · D2024-12-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 did not develop a person-centered care plan for 1 of 12 sampled residents (R35). The facility did not identify R35's individual choices and daily routines, which had the potential to negatively impact R35's quality of care and quality of life. During the comprehensive assessment, R35 indicated a desire to smoke. R35's comprehensive care plan did not address R35's preferences for smoking, which resulted in R35 complaining of not being able to smoke, feeling frustrated with staff, and expressing negative behaviors. Findings include: Review of the facility's policy titled Smoking Policy read, .Any resident who is deemed safe to smoke, with to without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan . Review of the facility's policy titled Comprehensive Care Plan read, .It is the policy of this facility to develop and implement a comprehensive…

    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 · D2024-12-18 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 did not ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 2 residents (R28) reviewed. The facility did not implement R28's Range of Motion (ROM) developed plan of care. This is evidenced by: R28 was admitted to the facility on [DATE]. R28's diagnoses, that include but are not limited to, are hemiplegia affecting right dominant side, rheumatoid arthritis, and right shoulder contracture. R28's Minimum Data Set (MDS) annual assessment dated [DATE] and quarterly assessment dated [DATE] were reviewed. R28's Brief Interview of Mental Status (BIMS) score is 15 out of 15, indicating cognition is intact. R28 requires the assist of 1 staff member with transfers and bed mobility. R28's ROM is impaired on one side of upper extremity and both sides of lower extremities. R28 requires substantial/maximal assistance with activities of daily living…

    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 before2024-12-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    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 did not use a gait belt to promote safe transfer for 1 of 2 residents. (R9) This is evidenced by: Surveyor reviewed the facility's policy titled, NSG-Safe Resident Handling and Transfers. Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure, and comfortable experience .in accordance with standards and guidelines. The following numbers of sections relate to the numbered section in the policy. 1. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other facts as well, such as weight and cognitive status. 2. The resident's mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations. 4. Handling aids may include gait belts, transfer boards, and…

    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 · D2024-08-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify resident's physician about a change in condition for 1 of 4 sampled residents (R)1. The facility did not inform physician about a deep tissue injury and change in vital signs for R1. Findings: The facility's policy titled, Change in Condition of the Resident, revised 09/20/2022, states in part: . When a resident presents with a possible change of condition, after a fall or other possible trauma, or noted changes in mental or physical functioning: 1. Assess the resident's need for immediate care/medical attention. Provide emergency care as needed. 2. Assess/evaluate the resident. This assessment/evaluation could include, but is not limited to the following: a. Vital signs . R1 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) of 11 which indicated a moderate impaired cognition, from an acute care hospital with diagnoses of malnutrition, multiple myeloma (also known as Kahler's disease, is an uncommon blood…

    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 · Fcited before2024-07-09 · tag F0880 — failed to prevent and control infections — widespread
    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 interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, and a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 51 residents in the facility. The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for scabies. Multiple nursing staff members worked when they had scabies and were being treated, then worked on multiple other resident units, thus exposing other residents to scabies. The facility did not have a tracking program in place for the early detection of exposed residents on these other units. This is evidenced by: According to the Centers for Disease Control and Prevention (CDC) standard of practice, .suggestions for developing guidelines for preventing, detecting,…

    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 before2024-07-09 · 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 interviews and record review, the facility did not ensure 1 of 3 residents (R2) were provided care and services to promote regular bowel movements (BM) that are in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. Findings include: The facility stated they did not have a policy or procedure on bowel management. R2 was admitted to facility from a hospital 06/18/24 to 06/22/24, with a diagnosis of compression fracture of T9-T10 vertebra and history of constipation. R2's last known BM was 06/16/24 and did not have a BM during admission to facility. R2's Minimum Data Set (MDS), dated [DATE], indicated that R2 had a BIMS of 13 (cognitively intact), dependent on staff for toileting and chair/bed transfer. MDS was marked not applicable for toilet transfers. R2 was ordered and received MiraLAX 17 grams mixed with 8 ounces of water daily for constipation. R2 was ordered and received Senna Plus…

    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 · D2024-07-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 interviews and record reviews, the facility did not calculate 1 of 3 sampled residents' (R2) fluid intakes who are at high risk for dehydration, in order to determine if meeting a sufficient fluid intake to maintain or improve proper hydration and health. This is evidenced by: The facility policy, entitled Hydration, dated 07/26/22 states, The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Sufficient fluid means the amount of fluid needed to prevent dehydration (output of fluids far exceeds fluid intake: and maintain health. The amount needed is specific for each resident and fluctuates as the resident's condition fluctuates (i.e., increase fluids if resident has fever or diarrhea). Both the American Medical Director Association and the American Dietary Association Guidelines recommend a minimum fluid intake of 1500 cc's (cubic centiliters)/day for adults regardless of body weight.…

    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 · F2023-10-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility did not ensure food is not stored and or prepared under sanitary conditions. This has the potential to affect all 57 residents. Thermometer not cleaned before taking temperature of food. Gloved hands used to touch meat that has touched other surfaces. Gloves used to prepare food not changed between tasks. Cake cooled in front of an open window. Findings include: On 10/24/23 at about 11:38 AM, Surveyor observed [NAME] G grab thermometer from the shelf to take the temperature of beef tips. After [NAME] G took the temperature, they cleaned the thermometer with an alcohol wipe and put the thermometer back on the shelf. Surveyor interviewed Dietary District Manager (DDM) F and asked what their procedure was for taking temperatures of food. DDM F indicated that staff should clean thermometer with an alcohol wipe prior to taking the temperature of food and in between each use. On 10/24/23, Surveyor observed [NAME] G grind up beef tips in the food processor. [NAME] G washed hands, put on gloves, grabbed a spoon out of a drawer and scooped…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-25 · tag F0880 — failed to prevent and control infections — pattern
    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 did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Staff observed not wearing proper Personal Protective Equipment (PPE) in a Resident (R) room on contact precautions for 1 of 1 resident on transmission based precautions. (R36) Staff did not offer hand hygiene in small dining room for breakfast served to 3 out of 8 sampled residents (R). (R14, R252, R102) Staff did not perform appropriate hygiene after allowing a resident to kiss and lick their arm. Staff did not perform hand hygiene during room tray delivery and between patient care areas for 6 out of 7 sampled residents. (R1-A, R20, R102, R103, R25, R24) R152 had personal cares perfromed where no hand hygiene was completed before donning gloves or after removing gloves. Findings include: According to the Centers for Disease Control…

    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 before2023-10-25 · 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 did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 4 residents (R26) reviewed for skin concerns. R26 had a left hip surgery on 6/22/23 requiring daily dressing changes along with comprehensive assessments after the removal of the wound vac on 6/27/23. The facility did not complete the ordered daily dressing changes and did not complete weekly comprehensive assessments of the incision site. This was evidenced by: The facility policy, entitled Pressure Injuries and Non-Pressure Injuries, dated 7/20/22, states: .For those residents with impaired skin integrity, they will receive care, treatment and services that seek to promote healing, prevent infection, and prevent further development of impaired skin integrity .Examples of impaired skin integrity include .surgical wounds . .If non-pressure: initiate the Non-Pressure Injury Tracker .Ensure appropriate treatment orders for each wound area, as…

    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 before2023-10-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    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 did not ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 1 residents (R26). R26, who is her own person, left the facility without letting staff know she was leaving. The facility was not aware R26 was missing until they received a call from R26's daughter. No interventions were put in place after the incident that would bring awareness of this behavior and prevent future unsafe behaviors. This was evidenced by: The facility policy, entitled Elopement/Unsafe Wandering, dated 8/09/22, states: .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-10 · 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 did not revise care plans to reflect the current toileting status was being performed for 1 or 1 resident (R2) reviewed for care plans. R2's care plan was not updated in the resident's closet to guide staff to place urinal slowly and ask what leg position is most comfortable. Findings include: R2 was admitted to the facility on [DATE] with diagnoses that include severe obesity and hydronephrosis with ureteropelvic junction obstruction. (The obstruction in this area impedes the flow of urine down to the bladder, causing the urine to back up in the kidney and dilate it.) R2's Minimum Data Set (MDS) assessment, dated 08/02/23, indicated that R2 required extensive assistance with toileting, personal hygiene, dressing and bed mobility. On 08/10/23 at 11:09 AM, Surveyor was reviewing R2's medical record regarding an allegation that CNAs were rough with cares. The investigation determined that no abuse had occurred, but R2 needed more care with placing the urinal due…

    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

“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

$36,552 in federal fines across 2 penalties.

  • $22,925 — penalty dated 2025-02-20
  • $13,627 — penalty dated 2024-08-26

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 3 of 52.7+0.3 vs chain
Health inspection 3 of 52.8+0.2 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 5Whitewater Health ServicesSt Charles, MN 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 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
NSHF OPERATIONS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/24/2017
MILLS, DAVIDIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST20%since 06/29/2017
CIBC BANK USAOrganization5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 12/31/2024
BAUMANN, TROYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/29/2017
HOEHN, JEFFREYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/29/2017
CLIFTONLARSONALLEN LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/12/2025
CONTINUUM THERAPY PARTNERS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
NORTH SHORE HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/09/2025
NSH REHAB LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
WIPFLI LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2002
BELONGIA, CHRISTINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2011
GEE, DARRENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/30/2021
GREER, LAURENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/29/2023
HOSTETLER, HARRYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2025
PATZER, COLLEENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/14/2023
PURTELL, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2018
SHRADER, KAIYAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/30/2025
NSHF WISCONSIN LLCOrganizationADP OF THE SNFsince 05/12/2025
OAKWOOD PROPERTY HOLDINGS, LLCOrganizationADP OF THE SNFsince 05/01/2022

CMS files one row per role, so the 36 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.

9 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.

$7.0M
Net patient revenuemost recent cost report
+6.7%
Operating marginrevenue minus expenses
$349K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 48%Medicare 15%Other / private 37%

This home reported $349K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$326per resident / day
operating cost
$9,915per month
≈ monthly operating cost
$349per 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 WI

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 Wisconsin Medicaid page.

Typical monthly cost in Wisconsin
$10,646/mo
Nursing home (semi-private)
$12,319/mo
Nursing home (private)
$6,540/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 525454. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-11, 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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