Complete Care at Jefferson Meadows LLC

Location & what’s nearby

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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

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.

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.

61.3% 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 78 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 72.5% 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 80 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 0.31 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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.

Staffing

How full it usually is: this home is certified for 102 beds and averages 49.5 residents a day — about 49% occupied, or roughly 52 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 3.92 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.20 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 3.41 hrs/resident/day on weekends vs 4.12 on weekdays — 17% thinner on weekends. RN hours go from 1.33 to 0.86 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% is well above 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

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

Inspection deficiencies

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

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 13 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · K2025-01-31 · tag F0700 — pattern
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure other alternatives were tried prior to installing/utilizing side rails. The facility failed to identify and recognize that the use of side rails with an air mattress increases the risk for entrapment for 12 of 12 residents in the facility (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12) who use a side rail and an air mattress. On 9/23/22, the facility implemented the use of a side rail for R1. The facility failed to ensure other alternatives were tried prior to installing/utilizing side rails/enabler device for R1. On 1/8/24, the facility changed R1's mattress to a Panacea Convertible Mattress with powered alternating-pressure therapy (a pump); the facility failed to complete an assessment for entrapment at this time. On 1/7/25, R1 became entrapped in the siderail resulting in the following three (3) fractures: 1. Left proximal humerus fracture (broken arm), 2. Right periprosthetic distal femur fracture (a break in the thigh…

  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
• Immediate jeopardy · J2023-02-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not implement professional standards of practice to ensure that a resident did not develop a pressure injury (PI) and that the resident received necessary treatment and services to promote healing and prevent infection of the pressure injury for 1 of 4 residents sampled for pressure injuries (R2). R2 had a history of pressure injuries and was at risk for PI development. The facility failed to implement aggressive measures upon admission, failed to update R2's MD timely when a new pressure injury developed, failed to re-evaluate interventions that were not working, failed to update the care plan timely, failed to complete diabetic foot checks per current standards of practice, and failed to use R2's offloading boots per manufacturer's guidelines. The facility did not consider changing course of action when 3 of R2's Medical Doctors noted the wound to be caused by pressure. R2 developed an infected stage IV PI. It should be noted thoroughout R2's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-05-13 · 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 Example 2 The facility policy titled Weight Monitoring dated 2/2025 states in part .1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional 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 .4. Interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status .6. Weight Analysis: The newly recorded resident weight should be compared to the previous weight. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days) b. 7.5% change in weight in 3 months (90 days) c. 10% change in 6 months (180 days) .7.…

  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 · D2026-07-02 · 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, record review, document review, and policy review, the facility did not ensure to prevent a resident elopement for one of four residents (Resident (R) 2) reviewed for wandering risks out of a total sample of eight residents. R2 exited the alarmed facility door, while unsupervised. Findings include: Review of the facility's policy titled, Elopements and Wandering Residents last revised June 2026 indicated, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.The facility is equipped with door locks/alarms to help avoid elopements.Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.Residents will be assessed for risk of elopement and unsafe wandering upon admission and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-05-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility did not ensure food was prepared and served in a safe and sanitary manner. This practice has the potential to affect all 48 residents who reside at the facility. Surveyor observed dietary staff directly touching food with bare hands. Surveyor observed staff enter kitchen area while food service was taking place, not wearing a hair restraint. Evidenced by: The facility policy, Food Safety Requirements, dated 2/25, states, in part; .7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. a. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas .d. Dietary staff must wear hair restraints to prevent hair from contacting food . On 5/12/25 at 7:26AM, Surveyor observed a dietary staff directly touching sausage with their bare hands. Surveyor observed dietary staff touching inside lip of fruit cups directly touching the food. Dietary staff was not wearing any gloves at the time. No hand hygiene was 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-13 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not assure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional practices and include the expiration date when applicable in 1 of 1 medication room. Surveyors observed the following: -6 stock antibiotic ointments were expired, found in the medication room: -3 antibiotic ointments (bacitracin zinc) expired on 12/22, 06/24, and 05/25 -1 triple antibiotic ointment (bacitracin zinc / neomycin sulfate / polymyxin B sulfate) expired on 12/23 and 2 expired on 01/25 Evidenced by: The facility policy, Medication Storage, dated 2/2025, states in part: Policy: It is the policy of this facility to ensure all medications house on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations .8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated,…

  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 · E2025-05-13 · tag F0842 — failed to keep accurate, complete medical records — pattern
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized in accordance with accepted professional standards and practices in 13 of 13 residents reviewed (R26, R3, R41, R21, R19, R31, R13, R42, R36, R25, R20, R5, & R15). The facility did not have readily accessible MD/NP visit notes for R26, R3, R41, R21, R19, R31, R13, R42, R36, R25, R20, R5, and R15. Evidenced by: The facility policy titled Physician Visits and Physician Delegation dated 2/2025 states in part .1. The Licensed Nurse should: a. Track due dates of physician visits .f. Remind the physician to date and sign all order and write a progress note .3. The Director of Nursing or Designee should: a. Conduct monthly audits for timeliness of physician visits . The facility's policy titled Documentation in Medical Record dated 2/2025 states in part Policy: Each resident's medical record shall contain an accurate representation…

  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 · E2025-05-13 · tag F0881 — failed to use antibiotics responsibly — pattern
  Implement a program that monitors antibiotic use.
  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 they followed standards of practice for an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 17 sampled residents (R42) and 3 of 4 supplemental residents (R300, R16 and R11) reviewed for antibiotic stewardship. R300 had documented urinary symptoms. The facility did not verify that infection criteria was met or monitor symptoms and effectiveness of treatment following the start of an antibiotic. R42 started an antibiotic for urinary tract infection (UTI). The facility did not verify that infection criteria were met, monitor symptoms through time of order for antibiotic treatment, or monitor symptoms and effectiveness of treatment following start of antibiotic. R16 started an antibiotic for UTI. The facility did not verify that infection criteria were met, monitor symptoms through time of order for antibiotic treatment, or monitor symptoms and effectiveness of treatment 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a residents right to be free from verbal abuse by a visitor for 1 of 13 residents (R3) reviewed for abuse. R3 was verbally abused on multiple occasions while at the facility by R3's Activated Power of Attorney (POA). The facility failed to ensure measures were in place to prevent verbal abuse from reoccurring. It was reported that R3's POA was yelling at R3 in December 2024. The facility completed an investigation regarding a possible verbal abuse by R3's POA on 3/27/25 and 4/21/25. The facility did not add appropriate interventions to ensure R3 was free from abuse, did not update R3's care plan with interventions, and staff were not aware of the need for extra support and/or monitoring when R3's POA was in the facility. Evidenced by: The facility policy, Abuse, Neglect and Exploitation, dated 4/8/25, states, in part; .Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-13 · 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 interview and record review, the facility failed to immediately intervene when alleged verbal abuse was observed for 1 of 3 Residents (R3) involved in a facility reported incident. Staff heard an alleged verbal abuse altercation and failed to immediately ensure R3's safety. Evidenced by: The facility policy, Abuse, Neglect and Exploitation, dated 4/8/25, states, in part; .VI. Protection of Resident .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the residents from the alleged perpetrator; E. Protection from…

  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 · D2025-05-13 · tag F0645 — isolated
  PASARR screening for Mental disorders or Intellectual Disabilities
  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 follow through with the appropriate steps of the Preadmission Screening and Resident Review (PASSR) process for 2 of 5 residents (R23 and R20) reviewed for PASSR screening. R23 did not have a PASSR level I (1) completed. R20 did not have a PASSR level II (2) completed. This is evidenced by: The facility's Resident Assessment-Coordination with PASRR Program, dated 2/2025, states, in part: This facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder (MD), intellectual disability (ID), or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. A. PASRR Level I-initial…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-13 · tag F0679 — failed to provide activities — isolated
  Provide activities to meet all resident's needs.
  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 an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This affected 1 of 5 residents (R25) reviewed for activities. Surveyor observed R25 on 5/7/25 and 5/8/25 sitting in the hallway with no meaningful activities. Surveyor observed R25 on 5/7/25 at 9:41 am positioned staring at a wall. Surveyor observed R25 again at 10:46am, 11:20am sitting in same position. R25's daily activity documentation showed R25 napped and roamed the halls most days from January 2025-May 2025. Evidenced by: The facility policy, Activities, dated, 2/25, states, in part; .It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well…

  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 · D2025-05-13 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure residents who receiving nutrition and medication by G-tube (Gastrostomy tube, a thin flexible tube inserted through a small incision in the abdomen and into the stomach, used to provide nutrition and fluids) receive the appropriate treatment and services. This affects 1 of 1 residents (R42) reviewed for tube feedings. The facility did not properly check placement of R42's G-tube prior to administering tube feeding. This is evidenced by: The facility's policy entitled, Care and Treatment of Feeding Tubes, dated 4/2/25, states, in part: Policy: It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . 1. Feeding tubes will be utilized according to physician orders . 4. The facility will utilize the Registered Dietitian in estimating and calculating a resident's daily nutritional and hydration needs . 6. 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

Fines & penalties

$54,326 in federal fines across 2 penalties.

• $19,135 — penalty dated 2025-05-13
• $35,191 — penalty dated 2025-01-31

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

Part of a chain

This home belongs to COMPLETE CARE — 85 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 →

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

CMS files one row per role, so the 29 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $268K 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

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