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Golden Age Manor

220 Scholl Ct, Amery, WI 54001 · Government - County · 85 certified beds · (715) 268-7107 Medicare & Medicaid certified

Call the home — (715) 268-7107 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
265 Griffin St E · (715) 268-8000 · Call to confirm hours
Pharmacy
265 Griffin St E, East Entrance · (715) 268-0678 · Call to confirm hours
Grocery
210 Keller Ave S · (715) 268-5872 · Call to confirm hours
Park
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 2 of 5
Short-stay residentsrehab / post-hospital 4 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 fell from 3 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 increased15.7%16.1%15.4%typical
Long-stay residents who lose too much weight4.6%5.1%5.4%better
Long-stay residents with a catheter left in their bladder4.2%2.1%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.3%2.7%2.0%worse
Long-stay residents with depressive symptoms9.1%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 injury3.1%3.3%3.3%typical
Long-stay residents whose ability to walk worsened13.6%18.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication28.8%16.9%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers3.8%5.0%4.7%better
Long-stay residents with worsening bladder/bowel control21.3%24.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table29.7%15.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine94.1%82.2%79.4%better
Long-stay hospitalizations per 1,000 resident days2.261.661.67worse
Long-stay outpatient ER visits per 1,000 resident days3.872.291.80worse

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.

49.8% 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 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.8%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
40.4%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 40.4% 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 47 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 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 SNF49.8%CMS range 36.0–65.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 7.9–16.810.7%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 discharge40.4%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 discharge25.5%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 discharge23.4%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 discharge95.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened7.8%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 hospitalization7.0%CMS range 3.7–14.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 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

0.95
RN hours/ resident / day
0.30
LPN hours/ resident / day
2.58
Aide hours/ resident / day
3.82
Total nurse hours/ resident / day
0.66
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 85 beds and averages 58.7 residents a day — about 69% occupied, or roughly 26 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.95 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.58 is at or above 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 3.31 hrs/resident/day on weekends vs 4.03 on weekdays — 18% thinner on weekends. RN hours go from 1.06 to 0.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

6
deficiencies at the latest standard inspection (2026-06-24)
15
at the previous standard inspection (2025-04-10)

Deficiencies are fewer than at the previous inspection — improving. 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.

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · G2024-03-07 · 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 that 2 of 4 residents (R) reviewed for pressure injuries (PI) (R27 and R6) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R27 developed a stage II PI on 10/28/23. On 12/27/23, the PI reoccurred as a stage 3.The care plan for PI interventions was not updated since 12/4/2023. R27 was not repositioned as instructed on the PI care plan, nor had a support surface for a stage 3 PI. The PI reoccurred on 2/14/24, healed on 2/26/24 and reoccurred on 3/6/24 causing actual harm. R6 has a PI; repositioning was not done as indicated on the PI care plan to promote healing of R6's PI. This is evidenced by: Guidelines from the National Pressure Injury Advisory Panel (NPIAP) 2016, Pressure Injury Prevention Points, accessed 07, March 2024, Prevention Points | National Pressure Ulcer Advisory Panel (npiap.com), states in part: Turn and reposition…

    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 · Fcited before2026-06-24 · 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 interview, the facility did not store, prepare, distribute, serve food in accordance with professional standards for food service safety. This has the potential to affect all 62 residents. -Surveyor observed clean water pitchers not inverted on open shelf in kitchen. -Surveyor observed in the walk-in cooler an open bag of whipped topping, an open container of butter, and prepared cinnamon rolls in a baking pan without dates indicating when they were opened, prepared, or when they should be used by. -Surveyor observed in the walk-in freezer opened bags of potato wedges, vegetables, and berries all without dates of when they were opened. -Surveyor observed in the dry storage area opened packages of cookies, dried noodles, split peas, powdered pudding and gelatin mixes, all without dates indicating when they were opened or when they should be used by. Findings include: On 6/22/26 at 8:50 AM, during initial tour of the kitchen with Dietary Manager (DM) I, Surveyor observed clean pitchers on bottom shelf that were not inverted or covered. On a shelf below 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Fcited before2026-06-24 · 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

    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 5 of 62 residents residing in the facility. Improper hand hygiene was observed during personal cares for R4, R6, R13, R40. Staff did not disinfect mechanical lifts after use for R4, R13, and R40 observed transferring with a mechanical lift. Staff did not wear proper personal protective equipment (PPE) when caring for R30 who is on Enhanced Barrier Precautions (EBP).Example1 The facility policy, titled Handwashing/Hand Hygiene, dated 2000, states: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.1. Hand Hygiene is indicated:a. immediately before touching a resident;b. before performing an aseptic ask (for example.);c. after contact with blood, body fluids, or contaminated surfaces;d. after touching the resident'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.

    Infection Control Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · F2026-06-24 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    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 and interviews, the facility failed to ensure the Infection Preventionist (IP) is trained in the required specialized education for infection prevention and control. This has the potential to affect all 62 residents.-The facility failed to ensure Registered Nurse (RN) G, who is acting in the role of the facility's Infection Preventionist (IP), had completed specialized training in infection prevention and control.Findings include: On [DATE], Surveyor reviewed the documentation the facility had provided for proof of the IP's training and certification. Surveyor found a portion of the modules had certificates of completion from the Center for Disease Control (CDC) infection control program. The CDC training log stated expired for the certificate of IP final test indicating the test was not taken in the time allowed after completing the modules. The required IP course does not show the IP certification test was taken and passed. Surveyor requested missing documentation and proof of…

    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 no plan of correction
  • Potential for harm · Fcited before2026-06-24 · tag F0887 — widespread
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not maintain documentation of screening, education, offering, and current Coronavirus 19 (COVID) vaccination status to staff. This has the potential to affect all 62 residents.Findings include: The facility policy titled, Employee Infection and Vaccination Status, with a revised date of January 2024 states: 2. Employees are offered or provided with vaccinations per state or local agency policies/regulations. 3. Employees are provided with educational materials to make informed decisions for non-mandated vaccinations. If declined, a declination form is completed and placed in the employee's health record. 5. Documentation of vaccinations includes the signature of the licensed healthcare provider and the employee when being administered. Vaccinations that are declined by the employee are documented on the applicable declination form and placed in the employee's health record.On 06/23/26 at 10:10 AM, Surveyor asked RN G if the facility maintains staff documentation on screening, education, offering, and current vaccination status.…

    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 no plan of correction
  • Potential for harm · E2026-06-24 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 the Advanced Directives information related to resuscitation status was clearly identified on residents' medical records to ensure their life-sustaining wishes would be honored. This occurred for 9 of 18 sampled residents (R) reviewed for Advanced Directives. (R31, R5, R9, R7, R2, R59, R4, R30, and R32) R31's physician order noted code status of Do Not Resuscitate (DNR)/Do Not Intubate (DNI). R31's advance directive did not include R31's wishes for resuscitation, no DNR/DNI form was signed by R31 or R31's representative, and no documentation in R31's medical record regarding conversation with R31 regarding code status. R5's physician order noted code status of Do Not Resuscitate (DNR)/Do Not Intubate (DNI). R5's advance directive did not include R5's wishes for resuscitation, no DNR/DNI form was signed by R5 or R5's representative, and R5's medical record did not document any conversation being held with R5 regarding code status. R9'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 Rights Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Dcited before2026-06-24 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide pharmaceutical services, including procedures that ensure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident, for 1 of 1 resident (R32) reviewed. R32 did not receive prescribed eye drops per physician order. Findings include: The facility policies, titled Administering Medications and Instillation of Eye Drops, both dated 2001, do not address reordering of medication or what to do when medication is not available. Per CFR S483.70 (f) the facility must provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement as described. Per CFR S483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. R32 was admitted to the facility on [DATE] with a…

    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 no plan of correction
  • Potential for harm · D2026-03-30 · tag F0646 — isolated
    Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
    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 complete a Minimum Data Set (MDS) assessment for significant change in a timely manner.-R1 was admitted to hospice. The MDS assessment for significant change was not completed within 14 days.Findings include:Facility Policy titled, Comprehensive Assessments, last revised [DATE], states: Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual.The RAI User Manual states the Significant Change in Status Assessment (SCSA) must be completed by the end of the 14th calendar day following determination that a significant change has occurred.Surveyor reviewed R1's electronic health record. Last completed MDS assessment was completed on [DATE].R1 was admitted to hospice on [DATE]. A SCSA was started on [DATE] but was incomplete and never submitted. R1 expired on [DATE].On [DATE] at 2:50 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated the MDS assessments…

    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 · Dcited before2026-03-30 · 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 each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed (R4).R4 had a fall during a 1-staff transfer with mechanical lift. Per care plan, R4 required 2-assist. Findings include:Facility policy titled, Falls and Fall Risk, Managing, last revised March 2018, reads in part: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force.The staff, with the input of the attending physician will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls.Facility policy titled, Care Plans, Comprehensive-Centered, last revised March 2022, reads in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented…

    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 · F2025-04-10 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 60 residents residing in the facility. This is evidenced by: On 4/7/25 at 9:10 AM, Surveyor conducted initial tour of the kitchen with Dietary Manager (DM) D. Surveyor interviewed DM D and requested verification of DM D's qualifications. DM D directed Surveyor to the two certifications on her office wall. On 4/8/25, Surveyor was provided copies of the certifications. In review of the DM certification, Surveyor noted it is for a Food Protection Manager which is accredited by the American National Standards Institute (ANSI)-Conference for Food Protection (CFP). Completed 2023-8-10 and valid through 2028-8-10 from the Always Food Safe Company. On 4/9/2025 at 8:50 AM, Surveyor interviewed Nursing Home Administrator (NHA) A, as DM D was unavailable. Surveyor asked if the facility has a full-time dietician in house. NHA A indicated they do…

    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 · Fcited before2025-04-10 · 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 observation, interview and record review, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. The facility practices had the potential to affect all 60 residents. Foods stored in the walk-in-cooler were not labeled and dated and the Head [NAME] did not allow the thermometer probe to air dry after cleaning with isopropyl alcohol prior to inserting into foods items intended to be served to residents for lunch. This is evidenced by: The facility policies titled, Food Receiving and Storage revised December 2008, states in part, 7. All foods stored in the refrigerator or freezer will be covered, labeled and dates (use by date). The Food and Drug Administration (FDA) Food Code states in part, 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact…

    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
Show the remaining 20 citations
  • Potential for harm · Fcited before2025-04-10 · 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 Example 3 Facility policy titled, Enhanced Barrier Precautions, dated 05/01/24, states in part: It is the policy of this facility to implement enhanced barrier precautions for the preventions of transmission of multidrug-resistant organisms . 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be initiated for residents with any of the following: 1. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheters .) even if the resident is not known to be infected or colonized with a MDRO. The facility policy titled, Handwashing/Hand Hygiene revised October 2023 states in part, Indications for Hand Hygiene . c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching a resident's environment; f. before moving from work on soiled body site to a clean body site on the same resident; and g. immediately after glove removal. R9 was admitted on [DATE]. R9's current diagnoses include multiple sclerosis,…

    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 · F2025-04-10 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, the following elements: An Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use. This has the potential to affect all 60 residents in the building who may utilize antibiotics. The facility did not ensure a standard of practice for antibiotic use or surveillance was being utilized in the facility's antibiotic stewardship program. This is evidenced by: The Facility policy titled Antibiotic Stewardship Program, dated 10/23, states in part: The Infection Preventionist is responsible for monitoring; investigating and setting forth a control plan to prevent unnecessary infections. The IP is responsible for monitoring and trending the facility infection incidence rates and this information is reviewed quarterly assurance committee with the interdisciplinary team and medical director each at least quarterly . Surveyor reviewed infection surveillance logs dated from February 2024-March…

    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 · E2025-04-10 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation and record review, the facility did not take action through documenting grievances, conducting a thorough investigation of the issues identified or provide resolution of the concerns brought to the attention of facility staff regarding missing laundry items. This affected R27, R42, R47, R44, and R4. This is evidenced by: Procedure for completing complaint reports: 1. All sections in complaint/grievance box must be completed entirely. 2. 2. After the complaint is recorded determine if a complaint is related to misappropriation. If the answer is Yes, the Administrator must be notified immediately. 3. In documentation of investigation box, the person in charge in the building will need to start the initial investigation. This may include interviews with staff or other residents, observations, memos posted to particular staff, etc. Use the back of form to contribute other details of investigation. 4. If a plan can be implemented right away, please implement and resolve the complaint. 5. If further investigation needs to occur, etc. The IDT will assist 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-10 · 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 observation, interview and record reviews, the facility staff failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, to develop comprehensive person-centered care plans to meet residents' goals for pain for or adequately assess and treat pain for 5 of 5 residents (R) reviewed (R49, R1, R24, R30 and R35). -Facility did not provide adequate pain relief, properly assess for pain, or develop a pain care plan for R49, R35 and R1. -R24 had no non-pharmacological interventions for pain. Care plan did not include resident's desired/tolerable pain level or follow-up pain assessment. -R30 received tramadol (an opioid medication) for pain. The facility did not implement pain assessments or interventions to determine the effectiveness of the medication. This is evidenced by the following: Facility policy titled, Pain Assessment and Management, dated last reviewed on October 2022, states in part, .General Guidelines: 1. The pain…

    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 · D2025-04-10 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 policy review, the facility did not maintain confidentiality of resident medical record information for 3 of 5 sampled and supplemental residents (R45, R19, R16) reviewed. This is evidenced by: Facility policy titled, Confidentiality, Security, and Access to Protected Health Information, with an effective date of 08/19/03, states in part: Protected health information .written, verbal, or stored in paper, photographic, video, or electronic format .will remain confidential. 2. Protected Health Information (PHI) - Health information (medical record) that is identifiable to a specific individual and that is maintained or transmitted by a covered entity in any form, whether in oral, paper, or electronic form. Confidentiality and Security of PHI: 2. Care needs to be taken .in an area and manner that ensures client privacy. Surveyor reviewed facility's training for new hire employees included in the employee handbook titled, Privacy/HIPAA, with no date, states in part: .employees are…

    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 · D2025-04-10 · 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 and implement a comprehensive person-centered care plan addressing medical and nursing needs. This occurred for 2 of 15 residents (R), (R1, R3) reviewed. R1 did not have a care plan developed to monitor for adverse reactions when R1 was prescribed a diuretic medication. R3's care plans were not developed for hospice and end of life care. This is evidenced by: Facility policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of 03/2022, states in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .reflects currently recognized standards of practice for problem areas and conditions .interventions are chosen only after data gathering, proper consideration of the relationship between the resident's problem areas and their causes, and relevant clinical…

    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 · D2025-04-10 · 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 ensure care plans were revised to reflect residents' current needs and to provide the needed direction to staff in providing necessary care and services. The facility practice affected 1 of 15 residents' care plans reviewed (R55). R55 had recent increase in behaviors resulting in resident-to-resident altercations on 3/03/2025 and again on 4/1/2025. R55's care plan was not updated to reflect changes identified and the care the resident received. Findings include: Surveyor reviewed the facility's policy titled Care Planning -Interdisciplinary Team revised March 2022. The policy reads in part: Policy Statement The interdisciplinary team is responsible for the development of the resident care plans. Policy Interpretation an Implementation . 11. Assessments of the residents are ongoing, and care plans revised as information about the residents and residents' conditions change. According to the Resident Assessment Instrument, The comprehensive care plan is an…

    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 · D2025-04-10 · 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 observation, interview and record review, the facility did not ensure a resident with limited mobility receives appropriate restorative services, and assistance to maintain or improve mobility with the maximum practicable independence for 2 out of 6 sampled residents (R3 and R9). R3 and R9's passive range of motion (PROM) exercise programs were not completed as ordered. The programs were not reviewed and assessed for appropriateness. This is evidenced by: Example 1 R3 was admitted to the facility on [DATE]. R3's current diagnoses include Alzheimer's disease, dementia, constipation, hypertension, neuralgia, osteoarthritis of knee, muscle weakness, spinal stenosis, pain, transient ischemic attack, anxiety, dysphagia, hemiplegia and hemiparesis, dysphagia, atrial fibrillation, cognitive communication deficit. R3's Minimum Data Set (MDS), dated [DATE], documented R3's Brief Interview for Mental Status (BIMS) score as having severely impaired cognition. R3 is dependent on staff for all activities of daily…

    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 before2025-04-10 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide pharmaceutical services related to the accurate administration of inhaled medication for 1 of 2 residents (R), (R19) reviewed. This is evidenced by: Facility policy titled, Administering Medications, with a revised date of 04/2019, states in part: .22. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: c. the route of administration; d. the injection site (if applicable) R19 was admitted to the facility on [DATE] with a pertinent diagnosis of allergic rhinitis. R19's orders noted calcitonin spr 200/act instill one spray into 1 nostril once daily - alt nostril daily. On 04/09/25 at 7:24 AM, Surveyor observed medication administration performed by Licensed Practical Nurse (LPN) H. Surveyor observed LPN H administer the nasal spray into R19's right nostril. Surveyor observed LPN H document medication as administered. No documentation of which nostril was…

    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 · D2025-04-10 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 that a resident's drug regimen was free from unnecessary medications for 3 of 5 residents (R) reviewed for unnecessary medications (R35, R8, R9). R3 is on medications for sleep, without adequate indication for use for the medications melatonin and trazadone. R8 receives an antibiotic daily for urinary tract infection (UTI) prevention. R8 receives a sleep aid of melatonin and hydroxyzine for sleep without adequate indication for use and no sleep care plan with non-pharmacological interventions to promote sleep. R9 receives melatonin for sleep without adequate indication for use and no sleep care plan with non-pharmacological interventions to promote sleep. Example 1 Findings include: The facility policy titled Behavioral Assessment, Intervention, and Monitoring, dated 2001, states: 1. Residents will have minimal complications associated with the management of altered or impaired behavior. 2. Behavioral symptoms are identified using…

    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 · D2025-04-10 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 residents (R) who were prescribed psychotropic medication were comprehensively assessed for qualitative and quantitative data for individualized targeted behaviors and non-pharmacological interventions implemented for 2 of 4 residents (R1, R8) reviewed. R1 received trazodone, an antidepressant medication, for insomnia. The facility did not implement monitoring interventions to determine the effectiveness of the medication. R8 uses trazodone, an anti-depressant medication, to promote sleep with no adequate indications for use and no non-pharmacological intervention to promote sleep. R8 uses antipsychotic medication and psychotropic medications. Pharmacist requested a gradual dose reduction (GDR), and physician did not provide rationale to continue medication. This is evidenced by: Facility policy titled, Behavioral Assessment, Intervention, and Monitoring, with a revised date of 02/2025, states in part: Comprehensive Resident Assessment 2. As part…

    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 · Dcited before2025-04-10 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 maintain documentation of screening, education, and ensure offering of current Coronavirus 19 (COVID) vaccination for 1 of 5 residents (R) reviewed. (R1) This is evidenced by: The facility policy titled Influenza and Pneumococcal Vaccinations, dated March 2022, does not refer to COVID vaccinations. This was the only policy provided when requested. Two requests for a related policy were made. The CDC COVID 19 Staying Up to Date with Covid 19 Vaccines states in part: Everyone ages 6 months and older should get a 2024-2025 COVID 19 vaccine. It is especially important to get your 2024-2025 COVID 19 vaccine if you are ages 65 and older, are at high risk for severe Covid-19, or have never received a COVID 19 vaccine. R1 was admitted to the facility on [DATE] and was admitted with the diagnoses that include: Alzheimer's disease, edema, urinary tract infection, polyneuropathy, chronic kidney disease stage 3b, dementia, depression, anxiety disorder, tremor,…

    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 before2024-09-25 · 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

    Based on interview, the facility did not ensure residents (R) received adequate supervision in transferring with a mechanical lift to prevent the risk of falling. This occurred for 3 of 3 residents. (R5, R6 and R7). Findings include: On 09/25/24 at 1:31 PM, Surveyor interviewed Certified Nurse Assistant (CNA) C and asked CNA C about any staffing concerns. CNA C indicated that last week on 09/14/24 during day shift around 1:15 PM, CNA C had to be on CNA C's own to transfer three residents (R5, R6 and R7) to bed via Hoyer lift. CNA C indicated that CNA C knew that CNA C shouldn't be transferring R5, R6 and R7 on CNA C's own but had no choice. Surveyor asked CNA C to explain the events of the day. CNA C indicated that the other CNA working with CNA C had to leave for a family emergency and that left CNA C short on west wing. On 09/25/24 at 5:15 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B and asked if NHA A and DON B if aware there was a shortage of staff on 09/14/24. DON B indicated that no one called DON B, so DON B did not know that.…

    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 · Fcited before2024-03-07 · 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 observation, interview and record review, the facility failed to store, prepare and distribute food under sanitary conditions. Touching ready to eat foods with contaminated gloves had potential to affect 48 of 58 residents. Not taking temperatures of pureed and liquidized food. Improper hand hygiene by staff for R54, R27, R264 and R31. Bare hand touching of toast for 3 of 3 (R264, R11, R3) residents observed. Findings include: The facility policy, entitled Food Preparation and Service revised on November 2010, reads in part, Gloves can also become contaminated and/or soiled and must be changed between tasks. On 03/05/24 at 11:35 AM, Surveyor observed Dietary Aide (DA) T setting up trays for the tray line. DA T had gloves on, picked up a tray, then a meal slip, put a napkin and silverware on the tray, then with the same dirty gloves grabbed bread and placed it on the tray. On 03/06/24 at 9:53 AM, Surveyor interviewed Dietary Manager (DM) R and read the above observation to DM R and asked if that was the way bread should be served. DM R indicated that's the way DM R was…

    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 · E2024-03-07 · tag F0550 — failed to protect resident dignity and rights — pattern
    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 did not ensure residents (R) were treated with respect and dignity and cared for in a manner to enhance their quality of life. Facility staff stood over R4, R6, R28 and R20 while assisting them to eat. Facility staff used a clothing protector, the edge of a spoon, and rim of a cup to wipe R28, R32 and R4's face during dining. Findings include: Facility policy entitled, Assistance with Meals, last revised March 2022, stated in part, .Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals .avoiding the use of bibs or clothing protectors instead of napkins, unless requested by the resident . On 03/04/24 at 12:06 PM, Surveyor observed Certified Nursing Assistant (CNA) D assisting R28 and R4 to eat their noon meal. CNA D stood between both residents the entire time while assisting them to eat. On 03/04/24 at 12:36 PM, Surveyor observed CNA E walk over to R28 and assisted R28 to take a few more bites of lunch…

    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 · D2024-03-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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, record review and interviews, the facility did not ensure that 1 of 6 sampled residents (R) who are unable to carry out activities of daily living received the necessary services to maintain personal hygiene (toileting/incontinence care). (R7) Findings include: R7 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD), unspecified dementia, muscle weakness, diabetes mellitus, urge incontinence, scoliosis, and dysphagia. R7's minimum data set (MDS) assessment, completed on 02/17/24, confirmed R7 scored 03 during a Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R7 is incontinent of urine and frequently incontinent of bowels. R7 requires set-up assistance with eating. R7 requires substantial maximal assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R7's care plan was initiated on 02/25/20, and included 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-07 · 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 ensure residents received adequate supervision and assistance with eating to prevent the risk of choking. This occurred for 2 of 2 residents (R) reviewed for eating, (R3 and R7). Findings include: Example 1: R3 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dysphagia, gastro-esophageal reflux disease, dementia, and type 2 diabetes mellitus. R3's Minimum Data Set (MDS) assessment, completed on 11/21/23, confirmed R3 scored 05 during a Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R3 requires supervision and set-up assistance with eating. R3 requires substantial maximal assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R3's care plan was initiated on 09/26/19, and included the following interventions: ACTIVITIES OF DAILY LIVING (ADL) care plan: Feeding needs to be fed at meals…

    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 before2024-03-07 · 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 maintain an infection and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. -Improper hand hygiene/glove use for Foley catheter care and during dressing change for suprapubic catheter for 2 of 2 residents with catheters. (R15, R54) -Improper infection control procedure for resident on contact precautions. (R7) Findings: The facility policy entitled, Handwashing/Hand Hygiene last revised August 2015, stated in part: .7. Use an alcohol-based hand rub containing at least 70% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents . .e. Before and after handling an invasive device (e. g., urinary catheters, IV access sites) . .h. Before moving from a contaminated body site to a clean body site during resident care . .g. Before…

    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 · Bcited before2025-04-10 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 and interview, the facility did not ensure at least 100 square feet in a single resident room for 1 of 63 residents (R)58. R58 resides in a room that is less than the required 100 square feet in a single resident room. This is evidenced by: The state Operations Manual, titled Appendix PP- Guidance to Surveyors for Long Term Care Facilities, dated 8/8,24, states: Unless a variance has been applied for and approved under CFR (Code of Federal Regulation) 483.90 (e)(1)(ii), . (rooms must) Measure at least . 100 square feet in single resident rooms. R58 was admitted to the facility on [DATE] with diagnoses atrial fibrillation, anxiety, depression, malnutrition, unspecified mental disorder due to unknown physiological concern and attention deficit hyperactivity disorder. R58 scored as severely cognitively impaired, her speech is unclear but R58 is rated to be able to make herself understood usually and understands others. R58 is independently mobile and able to ambulate without assistance. During…

    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 date of correction
  • No harm found · Bcited before2024-03-07 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 and interview, the facility did not ensure at least 100 square feet in a single resident room for 1 of 58 residents (R)264. R264 resides in a room that is less than the required 100 square feet in a single resident room. This is evidenced by: During the entrance conference, it was noted facility has a room with less than the required square footage and is occupied by a resident. room [ROOM NUMBER] measures 96 1/2 square feet. On 03/04/24 at 9:35 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked about R264 living in a room with less than the required square footage. NHA A indicated that room [ROOM NUMBER] is still 96.5 square feet and the reason is that it is not cost-effective to remodel the room to expand. NHA A indicated they do usually explain this to residents and/or family and offer a different room if unhappy with this. NHA A indicated R264 was admitted to that room and the Power of Attorney (POA) explained the room's square footage with no concerns at that time. On…

    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 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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
POLK COUNTY-DEPT OF ADMINISTRATIONOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 01/01/1966
REESE, DANAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/28/2025

CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$6.9M
Net patient revenuemost recent cost report
+2.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 70%Medicare 7%Other / private 23%

About 70% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

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

$303per resident / day
operating cost
$9,219per month
≈ monthly operating cost
$309per 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 525507. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-24, 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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