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Augusta Health And Rehabilitation

901 Bridge Creek Lane, Augusta, WI 54722 · For profit - Corporation · 50 certified beds · (715) 286-2266 Medicare & Medicaid certified

Call the home — (715) 286-2266 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Dec 20231 actual-harm citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)

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 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
207 W Lincoln St Ste 1 · (715) 286-2270 · Call to confirm hours
Pharmacy
153 W Lincoln St · (715) 286-2515 · Call to confirm hours
Grocery
155 W Lincoln St · (715) 286-5352 · Call to confirm hours
Park
513 Colfax St · 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 5 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 increased20.8%16.1%15.4%worse
Long-stay residents who lose too much weight7.6%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder4.7%2.1%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection3.2%2.7%2.0%worse
Long-stay residents with depressive symptoms0.9%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 injury7.8%3.3%3.3%worse
Long-stay residents whose ability to walk worsened10.8%18.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.1%16.9%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers1.4%5.0%4.7%better
Long-stay residents with worsening bladder/bowel control13.8%24.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table17.1%15.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication5.3%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine92.9%82.2%79.4%better
Short-stay residents rehospitalized after admission16.1%23.1%22.6%better
Short-stay residents with an outpatient ER visit4.8%15.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.551.661.67typical
Long-stay outpatient ER visits per 1,000 resident days2.002.291.80worse

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.

50.4% 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 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.4%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
47.6%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 47.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 21 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF50.4%CMS range 38.6–66.251.5%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 7.0–14.510.7%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 discharge47.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge47.6%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 discharge38.1%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 identified92.3%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.9%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 worsened3.9%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.801.02Oct 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

RN hours/ resident / day
LPN hours/ resident / day
Aide hours/ resident / day
Total nurse hours/ resident / day
RN hoursweekends
34.8%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 50 beds and averages 36.3 residents a day — about 73% occupied, or roughly 14 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Weekend coverage: total nurse staffing is 3.68 hrs/resident/day on weekends vs 4.79 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.68 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below the national median of 45%.

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

4
deficiencies at the latest standard inspection (2026-04-08)
10
at the previous standard inspection (2025-02-06)

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.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · G2025-02-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the resident environment remained as free of accidents as possible for 2 of 4 residents (R29, R4) reviewed for accidents. The facility did not complete a thorough investigation of falls for root cause and implement interventions to prevent further falls. R29 had a fall on 12/19/24 that resulted in a left femur fracture and surgical repair. This example is cited at actual harm. The facility did not complete a thorough investigation of falls to determine staff following plan of care, root cause, monitor for trends, and re-assess interventions to prevent further accidents for R4. This is evidenced by: The facility Fall Evaluation, Intervention, and Reporting policy updated/reviewed 10/10/24 states: All residents will be evaluated for fall risk within 24 hours of admission, with ongoing monitoring as needed, and per CMS guidelines. Residents who sustain a fall will be evaluated at time of event and the following 72 hours. Procedure: A. All residents…

    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 before2026-04-08 · 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 provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections with the potential to affect all 37 residents.-Registered Nurse (RN) E did not perform glove change/hand hygiene appropriately during wound care to R10.-Laundry Aide (LA) G transported clean linens throughout the building uncovered.Findings include: Facility Policy titled, Wound Care Policy, last reviewed 08/2025, reads in part: The goal is to promote wound healing, prevent complications, and maintain the highest practicable level of resident health.Dressing changes must include hand hygiene, proper personal protective equipment (PPE). Example 1 On 04/06/26 at 9:45 AM, Surveyor observed Registered Nurse (RN) E perform a dressing change and wound treatment to R10's right forearm. RN E placed a drape on the over-bed table with supplies sitting on top. RN E donned gloves, removed the old bandage, and threw it away. RN E then cleaned the wound, applied skin prep to…

    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 · Ecited before2026-04-08 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview and record review, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional practice. This had the potential to affect 4 of 4 residents: (R6, R10, and R25) for proper storage of insulin, (R15) for nebulizer solution storage, and the potential to affect all 28 residents residing on the C-D wing for use of bisacodyl suppositories, tuberculin vaccine, and influenza vaccine.Findings:The facility policy titled, Medication Refrigerator Temperature Monitoring Policy last reviewed on 12/20/25, stated,PolicyAll Medications requiring refrigeration will be stored in a designated medication refrigerator maintained at temperatures between: 36 degrees Fahrenheit - 46 degrees Fahrenheit (2 degrees Celsius - 8 degrees Celsius)Temperature monitoring will be performed daily and documented to ensure compliance with regulatory standards.Temperature Monitoring Procedure1. Daily Temperature Checks Staff will:1. Check refrigerator temperature once per shift2. Record temperature on the Medication Refrigerator…

    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 before2026-04-08 · 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 to ensure the accurate administration of all drugs to meet the needs of each resident. This was observed for 1 of 6 residents (R31) observed during medication administration. Registered Nurse (RN) I did not administer the correct dose of medication to a R31.Findings:Facility policy titled, Medicated Creams, Lotions, Powders Administration last reviewed on 12/20/25 stated, 4. Apply Medication1. Perform hand hygiene and don gloves2. Clean and dry the area if necessary3. Apply thin layer unless ordered otherwise ex: use of dosage cardR31 was admitted on [DATE] with a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated R31 was cognitively intact. R31 had a diagnosis of chronic pain syndrome (pain that lasts for over three months).On 04/07/2026 at 7:15 AM, Surveyor observed RN I administer a topical medicated cream to R31. Surveyor observed RN I place a pea size amount of the medicated cream 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-08 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure the resident can use the assistive devices when consuming meals and snacks for 1 of 1 resident reviewed (R6).-R6 did not receive divided plate, setup, and straws with lids per the care plan.Findings include: Facility Policy titled, Comprehensive Care Plan Policy, no date, reads in part: [[NAME] Health and Rehab] will develop and maintain an individualized comprehensive care plan for each resident to meet their physical, psychosocial, and emotional needs.Purpose: to ensure residents receive coordinated, person-centered care that promotes the highest practicable level of well-being in accordance with federal and Wisconsin long-term care regulations.Implementation of Care Plan: All facility staff are responsible for implementing care plan interventions relevant to their role. Staff must review care plans regularly, follow documented…

    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 · F2025-02-06 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to ensure the facility's garbage was properly stored in the dumpster. The failure had the potential to promote a breeding ground for pests and rodents affecting all 39 residents within the facility. Findings: On 02/04/25 at 8:15 AM, during initial tour of the kitchen, Surveyor asked [NAME] (I) to show surveyor where the dumpsters were located. [NAME] I led Surveyor out the back of the facility where the dumpster was. The dumpster was overflowing with black garbage bags, and black garbage bags were piled against the dumpster all over the ground in front of and around the dumpster. Surveyor asked [NAME] I about this, and [NAME] I indicated the facility is in outbreak. The facility has always used Styrofoam containers during an outbreak. On 02/04/25 at 11:45 AM, Surveyor asked Dietary Director (DD) H about the dumpsters overflowing and garbage on the ground. DD H indicated the garbage gets picked up twice a week on Tuesday and Thursday. The facility is in outbreak right now and we are using Styrofoam containers instead 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility did not consult with a physician as indicated by ordered parameters with a significant weight change for 2 of 2 residents (R) R4 and R14. This is evidenced by: The facility policy titled, Notification of Changes Policy, last updated on 01/10/25, states: It is the policy of this facility that changes in a resident's condition or treatment, are immediately shared with the resident and or the resident representative, according to their authority, and reported to the attending or delegate. Example 1 R4 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, chronic kidney disease and diabetes mellitus type 2. R4's annual Minimum Data Set (MDS), dated [DATE], Section K, indicated R4's weight of 193# and no indication of a physician-prescribed weight loss or weight gain regimen. R4's orders, dated 12/14/2023, state to obtain weight daily and notify physician if more than 3 lbs in 1 day or 5 lbs in 1 week. R4 has an order dated 12/12/23 for…

    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 · D2025-02-06 · 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 and interview, the facility did not accurately code the Minimum Data Set (MDS) assessments for 3 of 12 residents (R) reviewed. (R4, R29 and R32). The facility did not accurately code R4, R29 and R32's MDS assessment with correct number of falls that occurred during the referenced time frame. This is evidenced by: Example 1 R4 was admitted on [DATE] and current diagnoses included, in part, type 2 diabetes mellitus with diabetic nephropathy, epilepsy, age-related osteoporosis, peripheral vascular disease, congestive heart failure, malignant neuroendocrine tumors, malignant neoplasm of liver, chronic kidney disease stage 3b and depression. Review of MDS dated [DATE] an annual assessment documented Brief Interview of Mental Status (BIMS) score of 15, indicating R4 is cognitively intact. Section J documented R4 having 1 fall with no injury, 1 fall with injury not major and 2 or more with major injury. The previous MDS was completed on 08/31/24. Review of fall history during the period between…

    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 · D2025-02-06 · 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 interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections from the catheter. For 1 of 1 resident (R32) reviewed with a Foley catheter. R32's Foley catheter was changed on a routine monthly basis without clinical indications and not following professional standards of practice. This is evidenced by: The Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for prevention of catheter-associated urinary tract infections 2009, read in part, E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Facility's policy titled, Catheter Care, Urinary with 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 · D2025-02-06 · 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

    Based on record review and interviews, the facility did not ensure acceptable parameters of nutritional status, such as usual body weight or desirable body weight range by recognizing or assessing a significant weight loss for 1 of 1 resident (R14) reviewed. This is evidenced by: The facility policy titled: Notification of Changes Policy, last updated on 01/10/25, states in part, Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and their resident's physician, to ensure best outcomes of care for the resident. R14 was admitted to facility on 12/03/24 and has a Brief Interview for Mental Status (BIMS) of 11 out of 15, indicating mildly impaired cognitive level. R14's admission assessment Minimum Data Set (MDS) with target date of 12/09/24, Section K: weight 149# (note: this was an incorrect entry into MDS). R14's care plan, dated 12/12/14, stated R14 is at nutritional risk due to diagnoses of hypertensive heart disease chronic kidney disease, congested heart…

    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 before2025-02-06 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility did not ensure staff followed procedures for the accurate administration of medication for 1 of 1 resident (R25). Staff administered multiple medications at once via gastrostomy tube. This is evidenced by: Facility policy titled, Gastrostomy Intermittent Tube Feeding/Medication, with no date states in part: Policy: Licensed nursing staff will feed/provide medication through a resident's gastrostomy tube following orders of the physician. Procedure: 12. Pour 1 ounce (30 cc) of room temperature water into the syringe barrel to check for patency. If water flows freely, the gastrostomy tube is patent. 13. Administer medications at this time, as ordered by the physician. - Administer one medication at a time. - After each medication, flush the gastrostomy tube with a small amount of water. On 02/05/25 at 7:14 AM, Surveyor observed Licensed Practical Nurse (LPN) F training LPN G on medication administration. Surveyor observed LPN F instruct LPN G to remove R25's 6 ordered medications from the blister packs, crush them per order, and place…

    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
Show the remaining 13 citations
  • Potential for harm · Dcited before2025-02-06 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility did not ensure controlled drugs were stored in separately locked, permanently affixed compartments for 1 of 2 med storage units. Observation of a controlled medication stored in the unlocked refrigerator located in the medication room. Findings include: The facility policy, titled Controlled Substances, dated 04/24, states: .3. Controlled substances are stored in the medication room in a locked container, separate from containers for any con-controlled medications. On 02/05/25 at 9:01 AM, Surveyor observed medication storage area near E dining room with Licensed Practical Nurse (LPN) F. Surveyor observed the medication room door was locked; however, the refrigerator was unlocked with an open 30ml bottle of Lorazepam for R11. LPN F stated the refrigerator should have a lock, but not that long ago we got a new refrigerator, and they never replaced the lock. On 02/05/25 at 12:00 PM, Surveyor interviewed Doirector of Nursing (DON) B regarding finding of a bottle of opened Lorazepam in refrigerator which was not locked in med room. DON B…

    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 · D2025-02-06 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents received routine dental services for 1 of 1 resident (R25) reviewed. This is evidenced by: State Operations Manual Appendix PP states in part: The facility must assist residents in obtaining routine and 24-hour emergency dental care. The facility must provide or obtain from an outside resource, in accordance with §483.70(f) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan. R25 was admitted to the facility 04/07/23 with pertinent diagnoses of hemiplegia and hemiparesis (immobility/weakness) following cerebral vascular accident (stroke), malignant neoplasm of brain (tumor), dementia, dysphagia, and depression. R25's most recent Minimum Data Set (MDS) quarterly assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment, is sometimes understood, and sometimes understands. R25…

    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 before2025-02-06 · 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 and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 5 care observations for residents (R) (R13, R192, R6). Staff did not complete appropriate hand hygiene while providing care for R13's personal cares. Staff did not complete appropriate hand hygiene while providing care for R192. Staff used a contaminated scissors and used dirty gauze to complete wound care for R6. This is evidenced by: Facility policy titled, Handwashing/Hand Hygiene, with a revised date of 10/23 stated in part: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for Hand Hygiene 1. Hand hygiene is indicated: f. before moving from work on a soiled body site to a clean body site on the same resident; Example 1 R13 was admitted to the facility on [DATE]…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-25 · 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, staff interview and record review, the facility did not ensure the comprehensive plan of care was implemented by staff for 2 of the 5 residents (R5 and R4) reviewed. R5's care plan was not followed to receive ambulation assistance to meals. R4's care plan was not followed to lie down for 1-2 hours between meals. This is evidenced by: Example 1: R5 was admitted to the facility on [DATE], with diagnoses including malignant neoplasm of bladder, hypertension, anemia, and anxiety disorder. R5's minimum data set (MDS) assessment, completed on 06/01/24, confirmed R5 scored 15 during a brief interview for mental status (BIMS), indicating impaired cognition. R5 requires set-up assistance with eating and oral hygiene. R5 requires moderate assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R5's care plan was initiated on 03/13/24, and included the following interventions: AMBULATION care plan: -Three times…

    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 · F2023-12-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness to all 38 residents (R) in the facility. Findings include: Facility policy entitled Dishwashing sanitization protocol, stated in part, . Before each use, staff must verify that the dishwasher is operating at the recommended high temperature for effective sanitization, sanitization color changing stickers must be used to verify that the dishwasher is achieving the required high temperature for proper sanitization, apply the color changing stickers to designated areas within the dishwasher before each cycle . Facility policy entitled Food storage policy, stated in part, .Food storage procedures for refrigerated storage are followed to diminished environmental and cross-contamination, working containers holding dry food that are removed from their original packages must be dated with the manufactured on or expiration date . Example 1 On 12/19/23 at 8:07 AM, Surveyor…

    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 before2023-12-20 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not maintain an infection prevention and control program to prevent Legionella, or provide hand hygiene to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect 38 of 38 residents (R) residing in the facility. Findings: Example 1 Water Management Plan The facility's policy titled, Legionella Surveillance, Detection and Management states, in part .The facility, has a water management program that is overseen by the Water Management Team. 1. The Water Management Team will consist of at least the following personnel: The Infection Preventionist, Facility Administrator, Medical Director, and Maintenance Director. 2. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 3. The water management program…

    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 · D2023-12-20 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to or ensure the reporting of a reasonable suspicion of a crime in accordance with section 1105B of the Act to law enforcement, or report an allegation of abuse immediately but not later than 2 hours after the allegation is made, to the state agency when a family member to resident abuse allegation was made. This occurred for 1 of 1 incidents (R) R8 reviewed. Findings: The facility's policy titled, Mistreatment, Neglect, Exploitation, Abuse and Misappropriation Prevention and Protection reads, in part . Abuse is any of the following acts committed by any person in contact with the resident: .Abuse also refers to verbal abuse, sexual abuse (non-consensual sexual contact of any type with a resident) .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm Sexual abuse is defined at §483.5 as 'non-consensual contact of any type with a resident.'…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-20 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not complete a thorough investigation of an allegation of sexual abuse for 1 of 1 resident (R8). Findings: The facility's policy titled, Mistreatment, Neglect, Exploitation, Abuse and Misappropriation Prevention and Protection reads, in part . Abuse is any of the following acts committed by any person in contact with the resident: .Abuse also sexual abuse (non-consensual sexual contact of any type with a resident .Sexual abuse is defined at §483.5 as 'non-consensual contact of any type with a resident.' In the event in which any of the above is suspected or identified, staff will immediately stop the situation from continuing, will ensure that the resident is protected facility. 1. The immediate supervisor will contact the Department Director, facility administrator . If the incident is considered an alleged resident rights violation, the investigation begins immediately. 3. If the allegation is of physical or sexual abuse-all non-emergent personal cares 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-20 · 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 develop and implement a comprehensive person-centered care plan addressing medical and nursing needs for residents with pressure wounds and non-pressure related skin disturbances. This occurred for 1 of 4 residents (R) reviewed. (R17). Findings include: The facility policy titled, Policy and procedure for the prevention and treatment of skin breakdown, states in part, Prevention of pressure injuries: b- The care plan for the skin integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. B. Lower extremity ulcers: III. Treatment of pressure injury- Update the care plan for skin integrity listing appropriate risk factors, turning intervals, and interventions as appropriate . Record review identified that R17 was admitted to the facility on [DATE]. R17's diagnoses included, in part, type 2 diabetes mellitus, and heart failure. R17's Brief Interview for Mental Status score (BIMS) was 14, indicating cognitive intactness.…

    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 · D2023-12-20 · 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 observations, interviews and record reviews, the facility did not provide wound care and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 1 of 3 residents (R187) reviewed. Findings include: Record review identified R187 was re-admitted to the facility on [DATE] with diagnoses including, in part, pressure ulcer of left heel and peripheral vascular disease. As of 07/25/23, R187's Brief Interview for Mental Status score was 11, which indicated moderate cognitive impairment. A review of the admission skin assessment progress note dated 12/12/23 stated in part, Open sore on lower left leg front, dried, blackened scabbed. Residents heels purplish and could early breakdown from pressure areas, dried, sore, painful when blanched, wraps bilaterally . A review of the order summary report on 12/15/23 identified that R187 had an order for wrap Bilateral Lower Extremities (BLE) with black compression socks knee-high and wraps for edema…

    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 before2023-12-20 · 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 ensure pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 1 resident (R) observed receiving insulin. (R17) Findings include: According to [NAME] Lily manufacturing use for Humulin R insulin, states in part, Inject Humulin R U-500 subcutaneously approximately 30 minutes before meals into the thigh, upper arm, abdomen, or buttocks. Factors that may increase hypoglycemia include changes in meal pattern, the timing of meals, changes in level of physical condition . Surveyor reviewed R17's medical record and review of the physician orders states to give Humulin R U-500 subcutaneous inject 265 units in the morning for diabetes, give Humulin R U-500 subcutaneous inject 280 units in the afternoon for diabetes, give Humulin R U-500 subcutaneous inject 280 units in the afternoon for diabetes. On 12/19/23 at 11:08 AM, Surveyor observed…

    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 · D2023-12-20 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 always serve food that was palatable and served at the right temperature for 1 of 6 sampled residents (R), R26. This is evidenced by: R26 was admitted to the facility on [DATE] with diagnoses that include, in part, hypertension, pain, and a history of falls. On 12/18/23 at 11:00 AM, Surveyor interviewed R26 who stated she is very unhappy with the food. R26 stated the food at the facility tastes bland, and it is always cold. The facility seems to have to take my food back and reheat it often. R26 stated she has complained to staff about this, but it has not improved. Record review indicates R26 has an order for a regular diet. R26's Minimum Data Set (MDS) assessment dated [DATE] showed R26 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points. This indicates R26 is cognitively intact. The MDS assessment also indicated R26 was independent with eating. On 12/18/23 at 12:17 PM, Surveyor observed the room tray cart…

    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
  • No harm found · B2023-12-20 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    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 staff interview and record review, the facility did not notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing for 2 of 4 residents (R) (R9 and R33) reviewed. Findings include: R9 was admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) of 15. Diagnoses included venous insufficiency (poor circulation) and diabetes. On 02/01/23, R9 was sent to the hospital due to a change in condition. R9 was admitted to the hospital with diagnoses that include sepsis related to bilateral lower extremity cellulitis. On 02/17/23, R9 returned to the facility following this hospitalization. On 12/19/23 at 9:30 AM, Surveyor reviewed R9's medical record and was unable to find a written notice of transfer provided to R9. R33 was admitted to the facility on [DATE] with a diagnosis of hemorrhagic stroke. On 10/17/23, R33 was sent to the hospital due to a change in condition. R33 was admitted to the hospital with diagnoses 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
AUGUSTA AREA HOME, INCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/1968
BRADLEY, JAHNIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/15/2013
KRUEGER, KIMIndividualCORPORATE OFFICER; ADP OF THE SNFsince 05/05/2011
VANDE ZANDE, VICTORIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/18/2025

CMS files one row per role, so the 10 rows in the source record cover these 4 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.

$5.8M
Net patient revenuemost recent cost report
-2.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 72%Medicare 5%Other / private 22%

About 72% 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 2024. 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

$426per resident / day
operating cost
$12,955per month
≈ monthly operating cost
$418per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 525535. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-08, 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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