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Pine View Care Center

400 County Rd R, Black River Falls, WI 54615 · For profit - Limited Liability company · 95 certified beds · (715) 284-5396 Medicare & Medicaid certified

Call the home — (715) 284-5396 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Dec 2025
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (32% 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 an abuse, neglect, or exploitation citation (F0600), cited Dec 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
610 W Adams St · (715) 284-4311 · Call to confirm hours
Pharmacy
125 W Broadway St · (608) 989-2919 · Call to confirm hours
Grocery
923 Main St · (715) 284-0450 · Call to confirm hours
Park
County Rd R · Typically dawn to dusk

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased19.0%16.1%15.4%worse
Long-stay residents who lose too much weight6.0%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder0.9%2.1%0.9%typical
Long-stay residents with a urinary tract infection4.8%2.7%2.0%worse
Long-stay residents with depressive symptoms0.0%5.7%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.9%3.3%3.3%better
Long-stay residents whose ability to walk worsened20.3%18.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication36.5%16.9%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers3.9%5.0%4.7%better
Long-stay residents with worsening bladder/bowel control12.8%24.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table18.6%15.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Long-stay hospitalizations per 1,000 resident days1.911.661.67worse
Long-stay outpatient ER visits per 1,000 resident days3.912.291.80worse

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

§ 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.

0.24U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 33% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.04
RN hours/ resident / day
0.49
LPN hours/ resident / day
2.36
Aide hours/ resident / day
3.89
Total nurse hours/ resident / day
0.73
RN hoursweekends
32.1%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 95 beds and averages 33.4 residents a day — about 35% occupied, or roughly 62 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 3.89 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.04 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 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 3.48 hrs/resident/day on weekends vs 4.05 on weekdays — 14% thinner on weekends. RN hours go from 1.17 to 0.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

1
deficiencies at the latest standard inspection (2025-09-17)
3
at the previous standard inspection (2024-07-03)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · F2026-04-29 · tag F0802 — failed to prepare enough nourishing food — widespread
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not ensure dietary staff had the appropriate competencies and skill sets to carry out the functions of the food and nutrition services. This had the ability to affect all 32 residents.Facility Cook's son, who is not an employee of the facility, was assisting with kitchen duties.The Division of Quality Assurance received concerns indicating [NAME] C was taking pictures in the facility kitchen and posting them on social media on 03/30/26 and photo evidence was provided. The photo contained a caption that read, Thank you Jesus for my son coming to work with me through this dbl . to help his mom out!! . The post showed identified son handling beverages. Surveyor reviewed [NAME] C's social media page and confirmed the photos and captions were still present and open to the public. Surveyor attempted to contact [NAME] C and was unsuccessful.The facility employee handbook Page 5 states in part . all employees will be required to submit a two-stage TB test upon hire. Page 9 states in part . that people are hired on a trial basis for the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-29 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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 have a right to be treated with respect and dignity, for 1 (R8) of 5 residents reviewed for resident rights.Certified Nursing Assistant (CNA) H searched through and removed items from R8's purse without permission while R8 was out of the room.Findings include:R8 was admitted to the facility on [DATE].On 04/13/26, R8's Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating R8 is cognitively intact.R8's diagnoses include aftercare following joint replacement surgery, hypertension, major depressive disorder, chronic pain syndrome, edema, and attention-deficit hyperactivity disorder.On 04/05/26, R8 reported Certified Nursing Assistant (CNA) H went through R8's purse while R8 was receiving a shower from CNA K. R8 reported CNA H removed Tylenol and other medications and had no business being in R8's purse. R8 reported R8's purse was in the nightstand tucked away, and R8 has no idea if CNA…

    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 · Dcited before2026-04-29 · 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 did not have evidence that all alleged violations are thoroughly investigated which involved 2 (R6 and R7) of 7 residents reviewed for abuse.The facility did not implement immediate interventions, update care plans, or complete monitoring in relation to a resident-to-resident physical altercation between R6 and R7. Findings include:Facility Policy titled, Resident Safety and Abuse Policy, last revised 02/2022, states Residents have the right to be free from abuse by anyone, including, but not limited to, facility staff, other residents.This system cannot guarantee that abuse will never occur. It can only assure that the facility is doing all that is within its control to prevent occurrences.All alleged violations will be thoroughly investigated.When cause or probable cause is determined, the resident care plan will be revised to ensure a corrective plan is in place to prevent recurrence.R7 was admitted to the facility on [DATE].On 04/28/26, R7's Minimum Data Set…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-29 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility did not revise 1 (R8) of 12 comprehensive care plans and include person-centered, comprehensive interventions.R8's comprehensive care plan was not updated with person centered interventions.Findings include:R8 was admitted to the facility on [DATE]. On 04/13/26, R8's Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating no cognitive impairment. R8's diagnoses include aftercare following joint replacement surgery, hypertension, major depressive disorder, chronic pain syndrome, edema, and attention-deficit hyperactivity disorder.Surveyor reviewed R8's baseline care plan dated 04/02/26 which indicated R8 was a stand and pivot transfer and was continent of bladder.Facility-reported incident report stated that on 04/03/26, R8 reported that Certified Nursing Assistant (CNA) F told R8 to go to the bathroom in R8's incontinent product. R8 told CNA F that R8 would not do that and ultimately CNA F did assist R8 to the bathroom. The report stated that CNA…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (R9) of 3 residents reviewed for accidents.The facility staff did not follow R9's care plan for transfer status. R9 is a Hoyer lift and staff utilize the sit-to-stand mechanical lift for transfers.Findings include:The facility policy titled, Resident Assessment Instrument and Person-Centered Care Planning, last reviewed on 04/2025, states: The Resident Assessment Instrument (RAI).is to be completed by the Interdisciplinary Team (IDT).to identify the strengths, goals, life history and preferences of the resident to develop a person-centered care plan, to provide the appropriate care and services for each resident and to modify the care plan and care/services based on the resident's status.R9 was admitted to the facility on [DATE].On 02/25/26, R9's Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 3/15 indicating…

    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 before2026-04-29 · 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 interview and record review, the facility did not ensure it had procedures in place to assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident or contacting the provider when a resident's medication(s) is not available for administration for 1 of 4 residents (R3).R3 was noted to have not received scheduled doses of ASA (aspirin), Bupropion, Famotidine, Fluticasone salmeterol inhaler, Amitriptyline, and Duloxetine. The facility policy titled Medication/Treatment Administration Error Policy last revised on 04/25, states: Protocol (1)(b): A facility medication/treatment error occurs when a prescribed medication is not available to be administered. Protocol (2)(f) A pharmacy medication error occurs when: a drug is unavailable from the pharmacy that the physician prescribed. Protocol (3) immediately upon discovery of a medication/treatment error, the nurse completes the top section of the Medication/Treatment Error Administration Report and turns it in to the director of nursing or administrator…

    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 before2026-04-29 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not ensure it had procedures in place to assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident or contacting the provider when a resident's medication(s) is not available for administration for 1 of 4 residents (R3).R3 was noted to have not received scheduled doses of Xarelto (anticoagulant) and Amiodarone.The facility policy titled Medication/Treatment Administration Error Policy last revised on 04/25, states: Protocol (1)(b): A facility medication/treatment error occurs when a prescribed medication is not available to be administered. Protocol (2)(f) A pharmacy medication error occurs when: a drug is unavailable from the pharmacy that the physician prescribed. Protocol (3) immediately upon discovery of a medication/treatment error, the nurse completes the top section of the Medication/Treatment Error Administration Report and turns it in to the director of nursing or administrator within 24 hours R3 was admitted to facility on 03/18/26 with…

    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 before2026-03-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not ensure staff followed transfer precautions to prevent accidents for 1 of 2 observations of resident (R)(R3) transfers.R3 was observed transferred by CNA D independently using lift equipment.This is evidenced by:Facility policy titled, Body Mechanics - Transfer Training, with a reviewed date of 11/2024, states in part: Purpose: To provide direction to nursing staff members for training of appropriate body mechanics and safe resident transfer techniques. Protocol: 1. Key Points: b. Reminder that for mechanical sit-to-stand use and mechanical full body lift use, two CNAs, licensed nurse staff or therapists are required to perform the transfer/lift.R3 was admitted to the facility on [DATE] with pertinent diagnosis of dementia.R3's most recent MDS assessment, dated 02/25/26, noted a Brief Interview for Mental Status (BIMS) score of 00,…

    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 before2026-03-23 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 ensure that residents are free of significant medication errors for 1 of 3 residents (R)(R3) reviewed for insulin administration.R3 did not have 2 doses of sliding scale insulin administered per physician order on 02/28/26 and 03/15/26 based on blood sugar result.This is evidenced by:Facility policy titled, Diabetic Blood Sugar Monitoring, with a reviewed date of 11/2022, states in part: Purpose: It is the policy of this facility that blood sugars will be measure and recorded on diabetics per physician orders or when symptomatic. Protocol: 5. If ordered, give sliding scale insulin as ordered by physician.R3 was admitted to the facility on [DATE] with pertinent diagnoses of type 2 diabetes mellitus without complications.R3's physician orders include insulin lispro (short-acting insulin) per sliding scale four times daily of 61-150=0 units; 151-200=2 units; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-400=10 units; >400=call MD.Surveyor reviewed…

    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 · D2025-12-03 · 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 1 of 3 residents (R1) right to be free from verbal abuse by a Certified Nursing Assistant (CNA).CNA G (Certified Nursing Assistant) was observed to be swearing at and treating R1 roughly when assisting with needs.Evidenced by:The facility policy titled Resident Safety Abuse Policy last reviewed 3/2024 states in part It is the policy of our facility to maintain a work and living environment that is professional and free from threat and/or occurrence of harassment, abuse (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion, physical or chemical restraints not required to treat the resident's medical symptoms, exploitation and misappropriation of resident property.Providing a safe environment is one of the most basic and essential duties of the facility. Employees have a unique position of trust with vulnerable residents. Having access to private information, being in a physically intrusive position and having…

    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
Show the remaining 12 citations
  • Potential for harm · D2025-12-03 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not ensure that the policy and procedures that prohibit mistreatment, abuse, and neglect of residents were implemented for 2 of 3 residents (R1 and R2) reviewed for abuse. The facility did not implement their abuse policy and procedure as the facility did not report allegations of abuse to the State Agency, did not fully investigate allegations of abuse or put measures in place to protect residents while an investigation was occurring for abuse allegations involving R1 and R2. Evidenced by: The facility's policy titled Resident Safety Abuse Policy last reviewed on 3/2024 states in part .8. Reporting Suspected Violations: a. The supervisor on duty shall IMMEDIATELY safeguard the resident(s) and immediately report all alleged violations involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source and misappropriation of resident property to the facility administrator, the Administrator will notify the DON (Director of Nursing) and/or others as appropriate. b. The administrator will report a reasonable…

    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 · D2025-12-03 · 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

    Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law though established procedures for 2 of 3 residents (R1and R2) reviewed for abuse allegations. A facility staff member reported an allegation of abuse regarding R1 that was not reported to the State Agency or police. R2's family member reported an allegation of abuse that was not reported to the State Agency or police. Evidenced by: The facility's policy titled Resident Safety Abuse Policy last reviewed on 3/2024 states in part .8. Reporting Suspected Violations: a. The supervisor on duty shall IMMEDIATELY safeguard the resident(s) and immediately report all alleged violations involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source and misappropriation of resident property to the facility administrator, the Administrator will notify the DON (Director 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-03 · 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

    Based on interview, and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that alleged violations are thoroughly investigated for 2 of 3 residents (R1 and R2) reviewed for abuse. A facility staff member reported an allegation of abuse regarding R1 that was not thoroughly investigated. R2's family member reported an allegation of abuse that was not thoroughly investigated. Evidenced by: The facility's policy titled Resident Safety Abuse Policy last reviewed on 3/2024 states in part .8. Reporting Suspected Violations: a. The supervisor on duty shall IMMEDIATELY safeguard the resident(s) and immediately report all alleged violations involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source and misappropriation of resident property to the facility administrator, the Administrator will notify the DON (Director of Nursing) and/or others as appropriate. b. The administrator will report a reasonable suspicion of a crime against any individual who is a resident of or is receiving care…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible for 1 or 3 residents (R3) reviewed for transfers.R3 was transferred using a sit-to-stand mechanical lift instead of a full body mechanical lift.This is evidenced by:The facility's policy Body Mechanics-Transfer Training, dated 11/24, includes: To provide direction to nursing staff members for training of appropriate body mechanics and safe resident transfer techniques. ii. If the resident has no ability to sit, stand, or bear weight, DON'T LIFT - use a mechanical assist.R3 admitted to the facility on [DATE]. R3 has a right below the knee amputation.R3's comprehensive care plan includes: 11/12/25 Transfer assist: Full body lift assist of 2.On 12/3/25 at 12:59 PM, Surveyor interviewed CNA H (Certified Nursing Assistant) regarding R3's transfers. CNA H indicated R3 is a full body mechanical lift per R3's care plan. CNA H indicated on 12/2/25 he used a sit-to-stand…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-09-17 · 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, staff interview and record review, the facility did not follow proper food handling practice to prevent foodborne illness. This had the potential to affect all 30 residents residing in the facility.Surveyor observed staff touch ready to eat foods with contaminated gloves.Findings:Facility policy titled, Dietary Department- Personal Hygiene and Cross Contamination Prevention, stated in part: 2. There will be no bare hand food contact with any ready-to-eat foods to help prevent the transfer of viruses, bacteria, or parasites from hands to food. Other pre-approved, alternative procedures for handling and serving ready-to-eat food will be utilized (i.e. use of tongs, serving spoons or forks, use of waxed paper squares, clean glove use, etc.).On 09/16/2025 at 7:39 AM, Surveyor observed [NAME] C wearing single use gloves while cooking. [NAME] C was observed touching multiple potentially contaminated surfaces with gloved hands. Surveyor observed [NAME] C touch the serving tabletop, aluminum foil box, ladle, spatula, microwave, and Robo coupe puree machine. [NAME] C…

    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 · D2024-07-03 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not formulate an advance directive for the resident. Resident (R) 185 did not have orders for the advanced directive they elected for on file, or in a place for emergency personnel to retrieve the information if needed. This had the ability to effect 1 of 13 residents surveyed (R185). Findings include: The facility policy, entitled Cardiopulmonary Resuscitation (CPR) or Do - Not - Resuscitate (DNR) Orders, dated [DATE], states: 1. Upon Admission, the licensed nurse of social worker will discuss the options, CPR or DNR and any other advanced directives with the resident and/or legal representative and received the corresponding physician orders. The Physician Order Summery (POS) is the designated place in the medical record for staff to record/find the CPR/DNR designation for each resident. R185 was admitted on [DATE] to the facility and is able to be understood by peers and understands. On [DATE], record review of R185's hard charts and electronic record…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-03 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 a medication error rate of 5% or less. During the medication administration task, Surveyor observed 2 errors out of 27 medication opportunities, resulting in an error rate of 7.41%. This affected 1 of 4 residents (R17) observed for medication administration. R17 received two insulin injections by using injectable pens that a safety check was not completed on to ensure the injectable pens were dispensing insulin before administration. Findings include: Manufacturer's instructions for Basaglar Kwikpen (insulin glargine) state in part.Priming your pen: Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8:…

    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 before2024-07-03 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility did not ensure that potentially hazardous foods were served at temperatures that would reduce the chance of illness for residents. The facility did not cover food while transporting room trays past resident rooms and in hallways. This has the potential to affect 2 residents (R) (R1, R12) on a pureed diet and 3 of 8 residents (R6, R17, R5) receiving room trays. Findings include: The facility policy entitled, Food Temperatures, dated January 2024, states in part, 4. Take temperatures a. Cooking temperatures must be reached and maintained according to regulations, laws and standardized recipes while cooking . 5. The food service manager will a. review logs daily to ensure that appropriate temperatures are recorded and corrective actions are being taken. b. take corrective action as necessary. The facility policy entitled, Food Temperature Log, dated May 2024, states in part, HOT HOLDING:…

    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 · D2024-03-28 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility did not assist 1 of 13 sampled and supplemental residents (R19) with eating in a dignified manner by scooping food from her lip and chin with a spoon and feeding it to her. This is evidenced by: Surveyor requested and received the facility policy titled Meal Service Standards which is dated as last revised on 12/18. The policy in part reads: Purpose: The following meal service standards will ensure our residents have a safe, pleasant and enjoyable dining service. Protocol: 1. Dignity: h. All residents are served in a dignified and courteous manner. Surveyor reviewed R19's record and noted the following: The most recent quarterly Minimum Data Set (MDS) completed 12/28/24 notes R19 is dependent on staff to eat. On 3/26/24 at 12:49 PM, Surveyor observed Certified Nursing Assistant (CNA) E sitting at dining room table between R19 and another resident. R19 was faced away from the table in the wheelchair and CNA E was seated at table with her lunch tray. CNA E alternated bites of food that was pureed and drinks of beverages…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility did not ensure that 1 of 3 sampled and supplemental residents (R) who are unable to carry out activities of daily living received the necessary services to maintain good nutrition (assistance with meals). (R9) Findings include: R9 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia with anxiety, irritability and anger, depression, chronic diarrhea, peripheral vascular disease, osteoarthritis, and hypertension. R9's Minimum Data Set (MDS) assessment, completed on 01/12/24, confirmed R9 scored 01 during a Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R9 had weight loss and requires set-up assistance with eating. R9 requires substantial maximal assistance from staff for dressing and is dependent on staff for bathing, toileting, and transfers. R9's care plan was initiated on 10/14/23, and included the following: R9 is at nutritional risk due to dementia, forgets to drink…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-28 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not comprehensively assess 1 of 2 residents (R31) for trauma informed care and care plan approaches to mitigate any triggers to prevent re-traumatization. This is evidenced by: Surveyor requested and received the facility policy titled Providing Culturally Competent and Trauma-Informed Care dated as most recently revised on 8/22. The policy in part reads: Purpose: Residents who are trauma survivors will receive culturally competent, trauma informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Protocol: 1. Assessment: a. A multi-faceted approach to identifying resident history of trauma as well as his or her cultural preferences will be utilized. This includes asking the resident about triggers that may be stressors or may prompt recall of previous traumatic event; as well as screening 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 · Dcited before2024-03-28 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility did not provide pharmaceutical services to meet the needs of 1 of 1 resident reviewed for insulin administration (R31). This is evidenced by: The Bureau of Quality Assurance issued a memo dated 9/23/2003 (Memo number 03-014) which states that insulin is classified into five categories: Rapid-acting, Short-acting, Intermediate-acting, Long-acting, and Combination products. The memo points out that Rapid-acting, Short-acting, and Combination products start working within a short time frame and are meant to control blood sugar levels at meals. The memo states that it is important that the meal and administration of the insulin are properly timed to optimize blood sugar control. The memo also states that rapid-acting insulins (Novolog and Humalog) should be administered 0-15 minutes before meals or immediately following a meal. Drugs.com states in relation to meal service with Insulin Aspart: .Insulin Aspart (Novolog): Administer subcutaneously within 5 to 10 minutes before a meal . On 3/27/24 at 6:57 AM, Surveyor observed Registered…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to REAL PROPERTY HEALTH FACILITIES — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.1-0.1 vs chain
Health inspection 3 of 53.2-0.2 vs chain
Staffing 4 of 53.6+0.4 vs chain
Quality measures 2 of 52.7-0.7 vs chain
The other 8 homes this chain runs (chain average 3.1★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
CHRISTINA JAYNE PENN MANAGEMENT TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 11/01/2010
PENN, CHRISTINAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 06/01/2015
SUTTER, LESLIEIndividualW-2 MANAGING EMPLOYEEsince 11/01/2020
HAWORTH, ALBERTIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2021
MARSH, DAWNIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 04/15/1994
REAL PROPERTY HEALTH FACILITIES CORPOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 08/01/1989

CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$5.5M
Net patient revenuemost recent cost report
-11.9%
Operating marginrevenue minus expenses
$878K
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 43%Medicare 2%Other / private 55%

This home reported $878K paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$259per resident / day
operating cost
$7,870per month
≈ monthly operating cost
$231per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WI

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.

Typical monthly cost in Wisconsin
$10,646/mo
Nursing home (semi-private)
$12,319/mo
Nursing home (private)
$6,540/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525409. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-17, 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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