No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Ashland Health Services

1319 Beaser Ave, Ashland, WI 54806 · For profit - Limited Liability company · 117 certified beds · (715) 682-3468 Medicare & Medicaid certified

Call the home — (715) 682-3468 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure 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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1615 Maple Ln Ste 1 · (715) 685-7500 · Call to confirm hours
Pharmacy
522 Main St W · (715) 682-3123 · Call to confirm hours
Grocery
700 Main St W · (715) 682-8251 · Call to confirm hours
Park
623 12th Ave W · Typically dawn to dusk
Place of worship
1111 11th Ave W · (715) 682-6075

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 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 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 rating4★
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 increased25.9%16.1%15.4%worse
Long-stay residents who lose too much weight7.1%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder3.5%2.1%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.8%2.7%2.0%better
Long-stay residents with depressive symptoms1.8%5.7%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.6%3.3%3.3%better
Long-stay residents whose ability to walk worsened22.4%18.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication31.9%16.9%18.9%worse
Long-stay residents given the seasonal flu vaccine97.2%95.0%95.3%typical
Long-stay residents with pressure ulcers0.0%5.0%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control30.8%24.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table25.5%15.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication5.9%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine77.1%82.2%79.4%typical
Short-stay residents rehospitalized after admission24.5%23.1%22.6%typical
Short-stay residents with an outpatient ER visit11.4%15.5%12.0%typical
Long-stay hospitalizations per 1,000 resident days0.541.661.67better
Long-stay outpatient ER visits per 1,000 resident days1.262.291.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

44.6% 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 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.6%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
52.5%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 52.5% 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 40 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 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 SNF44.6%CMS range 31.6–57.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 5.8–15.410.7%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 discharge52.5%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 discharge52.5%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 discharge40.0%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 identified65.3%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 discharge100.0%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 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 hospitalization7.7%CMS range 3.6–14.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.151.02Oct 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

1.29
RN hours/ resident / day
0.15
LPN hours/ resident / day
2.16
Aide hours/ resident / day
3.60
Total nurse hours/ resident / day
0.97
RN hoursweekends
46.3%
Total nursing turnover
35.7%
RN turnover

How full it usually is: this home is certified for 117 beds and averages 37.6 residents a day — about 32% occupied, or roughly 79 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 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.29 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 3.25 hrs/resident/day on weekends vs 3.74 on weekdays — 13% thinner on weekends. RN hours go from 1.41 to 0.97 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as 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

2
deficiencies at the latest standard inspection (2025-08-06)
10
at the previous standard inspection (2024-06-05)

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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · Gcited before2023-06-28 · 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, observation and record review, the facility did not ensure all residents received treatment and care in accordance with professional standards of practice for 1 of 1 residents (R9) sampled for skin integrity out of a total sample of 12. R9 developed Moisture Associated Skin Damage (MASD) while residing in the facility. R9's schedule for offloading the area was not followed. R9 was having loose bowel movements that irritate and excoriate the skin; there was no follow up with the provider to reduce the laxatives to promote healing of the MASD. R9's MASD worsened, becoming larger in size and a new area of MASD developed. Findings include: The facility policy titled Pressure and Non-pressure Injuries, dated 8/2/21, states: .For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin…

    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 · D2026-06-08 · 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 resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R) reviewed. (R1)-R1 was transferred with only 1 person not with the assistance of 2 people, as indicated in R1's care plan to prevent falls.Findings include:The facility policy titled Fall Prevention and Management Guidelines last revised on 7/18/2024, states: The nurse will initiate interventions to help prevent falls on the resident's baseline care plan. a. Implement universal environmental interventions that decrease the risk of the resident falling.R1 was admitted to the facility on [DATE], with a diagnoses including dementia, bipolar disorder, depression, abnormal posture, weakness, unsteadiness on feet, and bilateral osteoarthritis of hip.Minimum Data Set (MDS), dated [DATE], which is a quarterly assessment documents R1 having a Brief Interview…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-08-06 · 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 failed to ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections such as COVID-19. This had the potential to affect all 36 residents.-The facility did not test staff with symptoms of COVID-19. -Staff used soiled cloth for catheter care and used a dropped alcohol wipe to disinfect the catheter of R7. Example 1 The CDC's COVID 19 website lists possible symptoms of COVID 19 which may include: Fever or chills Cough Shortness of breath or difficulty breathing Sore throat Congestion or runny nose New loss of taste or smell Fatigue Muscle or body aches Headache Nausea or vomiting Diarrhea The facility's policy titled Infection Prevention and Control Program, read in part .3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-06 · 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 interview, and record review, the facility did not implement a care plan to meet a resident's medical need for 1 of 5 residents (R) 5 reviewed for care plans.-CNA did not follow the care plan by not documenting R5's bowel movement for 2 days.R5 was admitted to the facility on [DATE] with diagnoses that include stroke with left sided paralysis, chronic pain, dementia, traumatic brain injury, epilepsy, anemia, and constipation. Minimum Data Set (MDS), dated [DATE], indicated R5 had a Brief Interview for Mental Status score of 99 meaning severe cognitive impairment. In addition, R5 is dependent on staff for eating, transfers, toileting, and extensive assist for bed mobility. R5 had an activated Power of Attorney for healthcare and finance. R5's care plan, dated 07/28/25, states: Bowel Elimination Alteration: At risk for constipation r/t: lack of exercise, medications. Interventions: Administer medications per MD order and observe effectiveness, . Record BM (bowel movement) . Repost (sp) S&S (signs 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-06-05 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to submit accurate data to Centers for Medicare and Medicaid Services (CMS) mandatory Payroll Based Journal (PBJ) for quarter 3 2023 (April 1-June 30), quarter 4 2023 (July 1-September 30), and quarter 1 2024 (October 1-December 31). This had the potential to affect all 40 residents. This is evidenced by: On 06/05/24 at 1:00 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A about the low weekend staffing data that was triggered in the PBJ report for the third quarter 2023 (April 1-June 30), fourth quarter 2023 (July 1-September 30), and quarter 1 2024 (October 1-December 31). NHA stated the issues with the data reporting were due to agency staff not punching their hours on the facility time clock, so the accurate hours were not in the facility computer system. Surveyor compared the data with time punches. Surveyor did not identify any concerns related to low weekend staffing coverage. The facility assessment states: Day shift: 2 licensed nurses, 3-5 CNAs Evening shift: 2 licensed nurses, 3-5 CNAs NOC shift: 1…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-06-05 · 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 observations, interviews, and record reviews, the facility did not establish and maintain an infection control program designed to help prevent the development and transmission of disease. This has the potential to affect all 40 residents. No surveillance log for staff infections. Staff did not apply gloves prior to entering rooms with residents on contact precautions. Precaution signs posted for Enhanced Barrier Precautions (EBP) and Contact precautions for R34 No process for reporting residents with Methicillin-Resistant Organisms (MRDO) when transporting to other facilities. This is evidenced by: Example 1: Facility policy titled, Infection Surveillance, dated as revised 03/08/23 states: Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections.…

    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 · F2024-06-05 · 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 40 residents. This is evidenced by: On 06/05/24, Surveyor reviewed the facility's infection control program and policies. The facility policy titled, COVID-19 Vaccination with revised date of 10/27/23 states: Policy: It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. Policy Explanation and Compliance Guidelines: 1. It is the policy of this facility to have an immunization program against COVID-19 in accordance with national standards of practice. 13. The facility will educate and offer the COVID-19 vaccine to residents, resident representatives, and staff and maintain documentation of such. 17. If a vaccination requires additional doses, the resident, resident representative, or staff member will be provided…

    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 · E2024-06-05 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 have a comprehensive system for ensuring 5 (R5, R8, R9, R24, R31) of 5 residents reviewed for immunizations received or were offered the pneumococcal vaccination. *R5 - No documentation of receiving or declining PCV 15 or PCV20. *R8 - No documentation of receiving or declining PCV20 or PPSV23. *R9 - No documentation of receiving or declining PCV20. *R24 - No documentation of receiving or declining PCV15 or PCV20 *R31 - No documentation of receiving or declining PCV15 or PCV20. This is evidenced by: According to the Center for Disease Control. (2024, February 6). Pneumococcal Disease in Adults and Vaccines to Prevent It. CDC Pneumococcal Disease. https://www.cdc.gov/pneumococcal/prevent-pneumococcal-factsheet/index.html#cdc_generic_section_6-vaccination, Two types of vaccines used in the United States help prevent pneumococcal disease in adults: conjugate and polysaccharide vaccines. Recommendations: Center for Disease Control (CDC) recommends…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-05 · 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 residents received treatment and care in accordance with professional standards of practice for 1 of 12 sampled residents (R23). The facility did not follow physician orders for R23 to obtain a video fluoroscopy swallow study (VFSS) to determine appropriate and safe diet recommendations. Findings: R23 was admitted to the facility on [DATE], after hospitalization for dehydration, confusion, and weakness. R23's hospital discharge instructions were speech therapy (ST) related to dysphagia (difficulty swallowing), occupational therapy (OT), and physical therapy (PT) for strengthening. Admitting diagnoses to facility included dementia, stroke with left sided paralysis, diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, and depression. R23's admission Minimum Data Set (MDS) assessment confirmed R23 scored 05/15 during Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. MDS determined R23 required partial…

    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 before2024-06-05 · 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

    Based on observations, interviews and record reviews, the facility failed to ensure staff practiced appropriate hand hygiene during a dressing change for a stage III Pressure Injury (PI) for 1 of 1 resident (R21) reviewed and currently in-house with a PI. The CDC had outlined the following indications for hand washing and the wearing of gloves: A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water . F. Decontaminate hands after contact with a patient's intact skin. G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled . J. Decontaminate hands after removing gloves . The CDC continues to direct healthcare workers with the technique of hand hygiene: .2. E. Change gloves during patient care if moving from a contaminated body site to a clean body site . Surveyor reviewed the facility policy titled Clean Dressing Change…

    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 before2024-06-05 · 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 interview and record review, the facility did not ensure 1 of 2 residents (R23) reviewed was offered sufficient fluid intake to maintain proper hydration. The facility did not have a system in place for tracking daily intakes to ensure R23's fluid intake was adequate. Findings include: Findings: The facility's policy, Hydration, reads in part, The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. 1. The facility will utilize a systemic approach to optimize the resident's hydration status: a. Identifying and assessing each resident's hydration status and risk factors. b. Evaluating/analyzing the assessment information. c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary. 3. Evaluation/analysis: a. The assessment shall clarify the resident's current hydration status and individual risk factors…

    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 12 citations
  • Potential for harm · D2024-06-05 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 ensure 2 of 2 residents (R31 and R1) reviewed for post-traumatic stress disorder (PTSD) received culturally competent trauma-informed care in accordance with professional standards of practice and accounting for each resident's experience and preferences in order to eliminate or mitigate retraumatization. This is evidenced by: According to Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) (https://www.ncbi.nlm.nih.gov/books/NBK207191/), The impact of trauma can be subtle, insidious, or outright destructive. How an event affects an individual depends on many factors, including characteristics of the individual, the type and characteristics of the event(s), developmental processes, the meaning of the trauma, and sociocultural factors. SAMHSA explains trauma causes immediate and delayed emotional, behavioral, physical, cognitive, and existential reactions. The facility's Trauma Informed Care policy, dated 10/18/22,…

    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 · D2024-06-05 · 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 observations, interviews and record reviews, the facility did not administer medications in a safe and effective manner for for 1 out of 1 resident (R1) observed having medications left at bedside. This is evidenced by: R1 has medical diagnoses that include, but are not limited to, chronic pain, chronic post-traumatic stress disorder, long term use of opiate analgesic and alcohol abuse, in remission. The most recent Minimum Data Set Assessment (MDSA) completed for R1 was a quarterly assessment with the ARD (Assessment Reference Date) 3/5/24. According to this MDSA, R1 has a Brief Interview of Mental Status (BIMS) of 15, indicating intact cognition. R1 has no mood indicators or behaviors listed. Surveyor then reviewed R1's care plan and noted the following: - History of substance use disorder as evidenced by history of addiction to alcohol, chronic opioid use. The start date of this problem was 12/4/23 and last revised 2/11/24. Interventions for this problem included: Nurse to remain in room at all times during medication administration due to history of hiding/hoarding…

    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 · Ecited before2023-06-28 · 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

    Based on observations and interview, the facility failed to 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. This practice had the potential to affect 13 residents residing in the facility. The facility did not provide hand hygiene to the residents before eating meals. This is evidenced by: The facility policy, entitled Dining Experience, dated 07/27/22, states: .Individuals will be provided with proper hand hygiene prior to each meal or snack . On 06/26/23 at 11:40 AM, Surveyors observed hall service meals. No hand hygiene was offered to the residents who ate in their rooms. R25, R27, R19, R7, R20, R10. On 06/26/23 at 11:50 AM, Surveyors observed staff assisting residents in the main dining room with lunch. No observation of staff offering hand hygiene to the residents before eating. No hand wipes or hand sanitizer in the dining room. R29, R9, R13, R15, R3, R6, R17. On 06/27/23 at 7:35 AM, Surveyor observed residents in…

    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 · D2023-06-28 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility did not complete and submit a Significant Change in Status (SCS) Minimum Data Set Assessment (MDSA) within 14 days after determining a SCS has occurred for 1 of 12 residents (R25) reviewed for assessments. This is evidenced by: The facility completed a SCS MDS with an Assessment Reference Date (ARD) of 3/11/23 for R25. The next assessment was due 6/11/23. However, R25 experienced a fall and sustained a fracture of the right hip on 5/21/23, significantly altering the plan of care. R25 returned to the facility from the hospital on 5/24/23. The facility completed a SCS MDSA with an ARD of 6/11/23. However, this assessment was not yet submitted as of 6/27/23. On 6/27/23 at 5:07 PM, Surveyor interviewed Staff K via telephone. Staff K is the Corporate Director of Clinical Reimbursement. Staff K stated that she oversees the MDS schedules and has direct discussions with the facilities regarding changes in residents that would constitute a significant change assessment. Staff K stated that she is the main contact for the MDSA's. Staff K…

    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 · D2023-06-28 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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, the facility did not ensure accuracy of Minimum Data Set Assessments (MDSA) for 2 of 12 residents (R16 and R25) reviewed. - Resident #16 was admitted [DATE]. An admission MDSA was completed with an Assessment Reference Date (ARD) of 1/6/23 in which several critical areas were left blank and not assessed, including that of Cognitive Status, Mood and Pain. - R25 did not have a Significant Change in Status (SCS) MDSA completed timely. When it was completed, the assessment did not include the development of a Stage II Pressure Injury to the Coccyx or the development of an Unstageable Deep Tissue Injury (DTI) to the heel. This is evidenced by: Example 1 R16 was admitted [DATE] with diagnoses that include but are not limited to Hemiplegia and Hemiparesis following Cerebrovascular Infarction affecting right dominant side, Abnormalities of Gait and Mobility, Difficulty walking, Dysarthria following Cerebrovascular Accident (CVA), Aphasia following CVA, Muscle Weakness, Hypertensive Heart Disease…

    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 before2023-06-28 · 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 observations, interviews and record review, the facility did not ensure a comprehensive care plan for pain management was achieved for 1 of 12 residents (R) reviewed for care plans (R10). R10 had pain in the perineal area related to vulvar (the outer surface area of female genitals) cancer with radiation burn to the area. The perineal area is the layer of skin between the genitals (vaginal opening) and the anus/sacral area. There was no care plan to direct staff on managing R10's pain. This is evidenced by: Review of the facility policy, entitled Pain Management, dated 8/09/22, states: .The facility .Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences .Based on the evaluation, the facility ., will develop, implement, monitor, and revise as necessary the interventions to prevent or manage each individual resident's pain beginning at admission. The interventions for pain management will…

    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 before2023-06-28 · 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 observations, interviews and record reviews, the facility did not ensure 2 of 4 residents (R25 and R27) reviewed for high risk of Pressure Injury development received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. - R25 has an existing PI to her coccyx and a Deep Tissue Injury (DTI) to her right heel. An observation was made of 3 hours 49 minutes in which staff did not offer or attempt repositioning or toileting. - R27 is high risk for the development of PIs. R27 was observed for 4 hours 29 minutes in which she was sitting in a Broda chair without staff offering or attempting to reposition or toilet. This is evidenced by: According to the NPIAP (National Pressure Injury Advisory Panel) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure…

    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 · D2023-06-28 · 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 1 of 3 residents (R25) reviewed for Urinary Tract Infections (UTIs) received the necessary treatment and services to prevent infections and to restore continence to the extent possible. R25 is currently being treated for an active UTI with antibiotic therapy. An extended observation was made of 3 hours 49 minutes in which toileting or incontinence care was not provided for R25 to keep R25 clean and prevent infection. This is evidenced by: The Long-Term Care Nursing Desk Reference. HCPro, Inc. Chapter 13, pages 214-215 offers the following discussion on urinary incontinence in Long Term Care: . Incontinence is a medical problem that is, in many instances, beyond the resident's control. Incontinence is not a normal consequence of aging and can frequently be cured or improved . Most believe that toileting residents every two hours is the best means of keeping them dry, when in fact this is a dated and ineffective method. Effective…

    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 before2023-06-28 · 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 observation, interview and record review, the facility did not ensure a resident maintains acceptable parameters of nutritional status and weight. This affected one of four residents Resident (R) 9, reviewed for nutrition and hydration. R9 was not provided the ordered supplement to maintain nutritional pararmeters, adaptive equipment was not provided as indicated on the care plan, facility did not follow up on dietician recommendations for multi-vitamin, nor was R9's intake accurately recorded by staff to ensure adequate nuritional intake. This is evidenced by: R9 admitted to facility 12/11/2017. Diagnoses include dementia, seizures, stroke affecting left side, depression, and anxiety. R9 has an activated Power of Attorney (POA) to assist in making healthcare decisions. Minimum Data Set (MDS), dated [DATE], confirmed R9 is understood and understands others. R9 scored an 8/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R9's care plan includes the following:…

    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 · D2023-06-28 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not ensure pain management was achieved for 1 of 1 resident (R) reviewed for pain (R10). R10 had pain in the perineal area related to vulvar (the outer surface area of female genitals) cancer with radiation burn to the area. The perineal area is the layer of skin between the genitals (vaginal opening) and the anus / sacral area. There was no current pain assessment or care plan to direct staff on managing R10's pain. This is evidenced by: Review of the facility policy, entitled Pain Management, dated 8/09/22, states: .The facility will utilize a systematic approach for recognition, assessment, treatment, and monitoring of pain .Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated .Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences .Observe for nonverbal indicators 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-28 · 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 in the presence of adverse consequences which indicate the dose should be reduced or discontinued for 1 of 5 residents (R) reviewed for unnecessary medications (R9). Facility did not follow up with provider after request to reduce laxative related to R9 having loose bowel movements. R9 continued to have loose watery stools with no change in laxative medications. Findings include: R9 admitted to facility 12/11/2017. Diagnoses include dementia, seizures, stroke affecting left side, depression, and anxiety. R9 has an activated Power of Attorney (POA) to assist in making healthcare decisions. Minimum Data Set (MDS), dated [DATE], confirmed R9 is understood and understands others. R9 scored an 8/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R9's care plan includes the following: Activities of Daily Living (ADLs),…

    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
  • No harm found · C2024-06-05 · tag F0680 — widespread
    Ensure the activities program is directed by a qualified professional.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a qualified activity professional was hired to direct the activities program and to meet the activity needs of residents. This had the potential to affect all 40 residents in the facility. The facility's Life Enrichment Specialist (LES) I or Activity Director, is not a qualified therapeutic recreation specialist and does not meet the qualifications required to direct the activities program. This is evidenced by: According to Federal Guidelines, the Activity Director must be a qualified therapeutic recreation therapist or must contain one of the following: Is licensed or registered, if applicable, by the State in which practicing; and (A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or (B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or (C) Is a qualified occupational therapist or occupational…

    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

“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.

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 4 of 52.7+1.3 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 3 of 53.4-0.4 vs chain
Quality measures 2 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 5Oakwood Health ServicesAltoona, WI 3 of 5Randolph Health ServicesRandolph, WI 3 of 5Rib Lake Health ServicesRib Lake, WI 3 of 5River's Bend Health ServicesManitowoc, WI 3 of 5Riverview Health ServicesTomahawk, WI 3 of 5Sheboygan Health ServicesSheboygan, WI

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 / managerTypeRoleSince
KURTZ, TAMMYIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2018
BAUMANN, TROYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2018
HOEHN, JEFFREYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2018
NORTH SHORE HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 02/01/2019
MILLS, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/01/2019

CMS files one row per role, so the 8 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$4.5M
Net patient revenuemost recent cost report
-5.9%
Operating marginrevenue minus expenses
$226K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 55%Medicare 13%Other / private 32%

This home reported $226K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$400per resident / day
operating cost
$12,156per month
≈ monthly operating cost
$378per 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 525386. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-06, 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.

What to do next