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

Grand View Care Ctr

620 Grandview Ave, Blair, WI 54616 · Non profit - Corporation · 50 certified beds · (608) 989-2511 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Feb 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$59,085 in federal fines1 Medicare payment denial
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)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $59,085 in federal fines (most recent 2025-02-25)
  • its facility-reported quality-measure rating is low (1/5)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
18601 Lincoln St · (715) 538-4355 · Call to confirm hours
Pharmacy
125 W Broadway St · (608) 989-2919 · Call to confirm hours
Grocery
30 2nd St · (715) 662-2225 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
126 Peterson Ave · (608) 989-2818

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 1 of 5
Long-stay residentspeople who live here 1 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 3 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 rating3★
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 increased18.2%16.1%15.4%worse
Long-stay residents who lose too much weight2.9%5.1%5.4%better
Long-stay residents with a catheter left in their bladder5.8%2.1%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection3.6%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 injury5.7%3.3%3.3%worse
Long-stay residents on antianxiety or hypnotic medication7.6%16.9%18.9%better
Long-stay residents given the seasonal flu vaccine83.7%95.0%95.3%worse
Long-stay residents with pressure ulcers2.8%5.0%4.7%better
Long-stay residents with worsening bladder/bowel control19.2%24.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table12.8%15.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Long-stay hospitalizations per 1,000 resident days4.081.661.67worse
Long-stay outpatient ER visits per 1,000 resident days5.922.291.80worse

* 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.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

44.7% 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 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.7%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
0.37U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 63% 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 some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF44.7%CMS range 29.1–60.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 7.1–16.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at 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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.9%CMS range 3.6–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.041.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.80
RN hours/ resident / day
0.59
LPN hours/ resident / day
2.91
Aide hours/ resident / day
4.30
Total nurse hours/ resident / day
0.47
RN hoursweekends
56.1%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 50 beds and averages 45.8 residents a day — about 92% occupied, or roughly 4 beds typically open. It runs fairly full. 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 4.30 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.91 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.67 hrs/resident/day on weekends vs 4.56 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.93 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as 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

5
deficiencies at the latest standard inspection (2025-04-17)
7
at the previous standard inspection (2024-01-24)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

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

  • Immediate jeopardy · Jcited before2025-02-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure residents received the necessary treatment and services consistent with professional standards, to prevent pressure injuries (PI) from developing and promote healing for 2 of 2 residents (R1 and R2) reviewed for PIs. R1 was admitted to the facility without a PI and was assessed to be at risk for PI development. The facility failed to implement robust interventions to prevent PI development, did not assess or stage the PI weekly and did not update care plan interventions timely. R1 developed a facility acquired PI that worsened to a stage 4. The facility's failure to complete weekly comprehensive PI assessments, offer alternate repositioning schedules, update the care plan and implement interventions for R1 created a finding of immediate jeopardy that began on 01/09/25. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on 02/13/25 at 12:30 PM. The immediate jeopardy was removed on 02/19/25; however, the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-02-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure the resident environment remained as free of accidents as possible for 1 of 3 residents (R7) reviewed for accidents. R7 has a history of falls and has had 8 falls since admission. On 01/27/25, the facility failed to ensure that R7's fall interventions were in place resulting in R7 having a fall with injury requiring staples to the head, as well as a skin tear. This is cited at actual harm. Findings: The facility's Fall - Clinical Protocol policy dated 04/03/23 states in part, Assessment and Recognition 1. As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. a. Staff will ask the resident and the caregiver or family about a history of falling. b. The staff and physician should document in the medical record a history of one or more recent falls. c. While many falls are isolated individual incidents, a significant proportion occur among a few…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-17 · 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 resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (R23) reviewed. R23 was left unattended while connected to mechanical lift equipment. This is evidenced by: The Food and Drug Administration (FDA) Safety Information guidance provided in Kwik points Patient Lifts Safety Guide, states in part: Do not leave patient unattended while in lift. Never keep patient suspended in sling for more than a few minutes. Facility policy titled, Lifting Machine, using a Portable, dated 2024, states in part: .#3. To transfer a resident from a bed to a chair, you should: v. Remain with the resident until he or she is comfortable and free of any adverse effects from the transfer . R23 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident with hemiplegia, atrial fibrillation,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections from the catheter, for 1 of 2 residents (R28) reviewed with a Foley catheter. R28's Foley catheter was changed on a routine schedule without clinical indications and not following professional standards of practice. This is evidenced by: The Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for prevention of catheter-associated urinary tract infections 2009, read in part: E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Facility policy titled, Catheter Care, Urinary, dated 2025, states…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to adequately assess and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 of 12 residents (R28) reviewed for pain management. R28 did not have an individualized pain assessment completed to monitor, assess, and evaluate for efficacy for pain management. This is evidenced by: Facility policy titled, Pain Assessment and Management, dated 2019, states in part: The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility did not ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. Facility did not determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This has the potential to affect all 44 residents in the facility. Findings include: Facility policy titled, Storage of Medications, dated 2012 reviewed on, states in part, .#7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . Facility policy titled, Controlled Substance policy and procedure, dated 03/27/25, states in part, .Shift count: #3. D. If the controlled substance count does not match, then: i. The oncoming nurse does NOT co-sign the count until the reconciliation has been…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, for 4 of 5 residents (R) reviewed (R1, R24, R27, R7). -Facility did not have open date labels on controlled medications that had been opened and were located in the medication storage room refrigerator for 3 of 4 residents (R) reviewed. (R1, R24, and R27) -Observation of R7's Lorazepam, which expired on [DATE], still located in medication storage room in unlocked refrigerator. Findings include: Facility policy titled, Storage of Medications, dated 2012, states in part, .#7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . On [DATE] at 8:05 AM, Surveyor toured medication storage room 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 · F2025-02-25 · tag F0944 — widespread
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    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 staff received Quality Assurance Performance Improvement (QAPI) program training. This practice had the potential to affect all 43 residents in the facility. The facility did not provide any staff with required training on the facility's QAPI plan. This is evidenced by: The facility's Quality Assurance & Performance Improvement Plan, dated 01/2024, states in part: Staff Training and Orientation In order for caregivers to become and remain proficient with quality improvement tools and techniques, QAPI principles and staff responsibilities related to QAPI, and ongoing quality improvement will also be included in orientation for all new employees. In order to become and remain proficient with quality improvement tools and techniques all staff will participate in ongoing annual QAPI training . On 02/25/25, Surveyor reviewed the facility's new orientation and annual education completed with staff. Surveyor observed no training identified as QAPI education. On 02/25/25 at 1:54 AM, Surveyor interviewed Nursing Home…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-25 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law for 1 of 1 incidents reviewed. R10 alleged being physically abused by Certified Nursing Assistant (CNA) J on 02/09/25 at 11:00 PM. This was not reported to the state until 02/11/25 at 2:55 PM. This is evidenced by: Review of facility's policy titled Abuse,…

    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 · F2024-01-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. Sanitization testing was not recorded, dishwashing temperatures were not recorded, and refrigerator temperature logs were not recorded. This has the potential to affect all 45 residents who reside in the facility. This is evidenced by: The facility policy, entitled Dishwashing Machine Use, states: .A dietary personal will check the dishwashing machine for proper concentrations of sanitizer after filling the dishwashing machine and every day to reach 160 degrees F using Chem Strips .The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log . On 1/21/24 at 9:45 AM, Surveyor observed during the initial tour of the kitchen that there was no documentation that the staff test the sanitization levels of the chemicals used in the buckets and sink water. Surveyor asked [NAME] K if they test the sanitation levels for these. [NAME] K said…

    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 · D2024-01-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure 1 of 12 (R3) residents reviewed for comprehensive care plans had a developed care plan specific to the resident. This is evidenced by: The facility policy, entitled Care Plans - Comprehensive, states: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems . On 1/23/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to diabetes and colitis due to Clostridioides difficile (C-diff). Review of R3's Minimum Data Set (MDS) assessment, dated 12/13/23, included the diagnosis of diabetes and colitis due to C-diff. Review of R3's care plan indicated there was nothing…

    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 · D2024-01-24 · 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 4 sampled residents, (R) R19, who are unable to carry out activities of daily living, receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This is evidenced by: The facility policy entitled: Repositioning, states in part .1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. 3. repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. R19 was admitted to the facility on [DATE] and placed on hospice for end-of-life care on 08/29/23 related to decline in status related to a diagnosis of atherosclerotic heart disease. R19's most recent comprehensive assessment was a significant change Minimum Data Set (MDS) assessment, dated 08/23/23, which indicated that R19 is dependent for all Activities of Daily Living (ADL), totally incontinent of bowel and bladder,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · Dcited before2024-01-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility did not ensure 1 of 2 sampled residents (R) R39 received treatment and care in accordance with standards of practice when R39 was not given medication as ordered. This is evidenced by: The facility policy, entitled Physician Medication Orders states: Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in this state. On 01/05/24, R39 was seen by urologist related to bladder urgency. The urologist ordered a laxative Polyethylene glycol 17 grams/dose powder oral in am. If not 1 bowel movement (BM) per day give additional 17grams at night related to findings of constipation and enlarged prostate. On 01/23/24, Surveyor reviewed R39's medication record which showed between 01/06/24 and 01/23/24, R39 did not have a bowel movement on 8 out of the 18 days (01/07/24; 01/10/24; 01/12/24; 01/13/24; 01/14/24; 01/16/24; 01/18/24; and 01/19/24) and did not receive the extra dose of prescribed polyethylene glycol at night. On 01/23/24 at 2:29 PM, Surveyor…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility did not ensure 1 of 1 residents (R) reviewed with a suprapubic catheters (R3) received appropriate treatment and services for the catheter. This is evidenced by: On 1/23/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses included, but not limited to benign prostatic hyperplasia, supra pubic catheter, prostate abscess, and urinary retention. Review of R3's Minimum Data Set (MDS) assessment, dated 12/13/23, included indwelling catheter. Review of R3's care plan indicated .I have a supra pubic catheter .I need my nurses to care for my catheter and change catheter . R3 had a suprapubic catheter placed on 7/10/23 due to retention and prostate abscess. Review of R3's urology note dated 8/16/23 stated, Under the order and the supervision of the Urologist. The patient is here for a routine suprapubic catheter change .The patient is scheduled for Q [every] 4 weeks SP [suprapubic] catheter changes to be done…

    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 before2024-01-24 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, staff did not perform sanitizing of durable medical equipment to prevent the spread of infection when warranted between 3 of 3 residents (R) (R11, R20, R21). This is evidenced by: The facility policy entitled: Cleaning and Disinfection of Environmental surfaces states in part .8. Equipment (EZ stand, lifts, etc.) used for multiple residents will be disinfected between residents. On 01/24/24 at 8:32 AM, Surveyor observed Certified Nursing Assistant (CNA) C remove the EZ stand lift out of R21's room after transferring R21 to a wheelchair. CNA C then took the lift to R20's room to transfer R20 to the wheelchair. CNA C then placed the EZ stand lift into the hallway cubby. Sanitizing of the lift before, between residents or after use was not observed by Surveyor. On 01/24/24 at 8:52 AM, Surveyor observed CNA C take the Hoyer lift from middle of the hallway to R11's room and transferred R11 into the wheelchair. Sanitizing of the lift before, during or after use was not observed by the Surveyor. On 01/24/24 at 9:47 at AM, Surveyor interviewed CNA 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-09 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an injury of unknown source, was not reported immediately but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law for 1 of 1 injury of unknown origin reviewed. (Resident R3) R3 was found to have an injury of unknown origin, bruising on her breast and hip. This was not reported to the state survey agency or law enforcement within 2 hours. This is evidenced by: The facility policy entitled Abuse, Neglect and Misappropriation dated 04/02/23, states in part; all alleged violations including abuse, neglect, exploitation, or mistreatment, including injuries of unknown…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-09 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not thoroughly investigate an injury of unknown origin for 1 of 1 injury of unknown origin reviewed. R3 was found to have an injury of unknown origin, bruising on her breast and hip. This was not thoroughly investigated. This is evidenced by: The facility policy entitled Abuse, Neglect and Misappropriation dated 04/02/23, states in part; all alleged violations including . injuries of unknown source .will be investigated. Injuries of Unknown Source: The source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury is suspicious because of: i. The extent of the injury, or ii. The location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma). The facility policy entitled, Bruises dated 2011, states in part; C.N.A. investigations for the last 24 hours. R3 was admitted to the facility on [DATE] with diagnoses including cerebral infarct dementia,…

    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 · Ecited before2022-11-30 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, such as COVID-19. During the three-day survey, staff were observed entering the rooms of Residents (R) on Droplet transmission based precautions (TBP) without putting on the proper personal protective equipment (PPE). (R35, R10, and R17) Facility staff did not offer 13 of 21 sampled and supplemental residents observed in dining rooms hand hygiene prior to eating. (R201, R39, R4, R20, R24, R12, R30, R22, R33, R11, R21, R45, and R25) Findings include: Example 1 According to CDC guidance located at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Health Care Personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure that a resident (R) with arterial wounds received the necessary care and treatment in accordance with professional standards of practice for 1 of 1 residents reviewed (R40). R40 has a lower extremity arterial ulcer that was not assessed weekly, documentation regarding the wound did not include all assessment data including, wound bed color, size, shape, location, drainage, and condition of surrounding tissue. The size is only documented 2 times over a 3 month period. This is evidenced by: The facility policy, entitled Wound Care dated 2015, states in part: The following information should be recorded in the resident's medical record .all assessment data (i.e. wound bed color, size, drainage, etc.) obtained when inspecting the wound. R40 was admitted to the facility in June of 2022, with diagnoses including: chronic atrial fibliration, acute embolism, acute combined systolic and diastolic heart failure, cardiac pacemaker, history of [NAME]…

    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 before2022-11-30 · 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, record review and interview, the facility did not implement care planned approaches for 1 of 1 residents (R150) reviewed with a pressure injury. This has the potential to delay healing of the pressure injury. The facility assessment of the pressure injury was not conducted in keeping with current standards of practice. R150 was admitted to the facility on [DATE] with pressure injury to her coccyx. The facility did not reposition R150 as directed in her plan of care. The facility assessment of the pressure injury did not include at least weekly documentation of wound staging, measurements and description of the injury. This is evidenced by: On 11/29/22 at 7:01 AM, Surveyor observed R150 up in her wheelchair in the dining room/lounge area. At 8:13 AM, R150 remained up in her wheelchair for breakfast. At 8:41 AM, R150 is taken to her room and is placed in front of the window in her wheelchair. R150 remained in her wheelchair in front of her window until 9:35 AM when she is transferred to bed…

    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 · D2022-11-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility administered medication intended to promote sleep without a system in place to monitor the effectiveness of the medication or care planned non-pharmacological approaches to address resident sleep disturbance affecting 2 of 2 residents (R45 and R43). R45 was prescribed Trazadone 50 mg (0.5 tablet/25 mg) nightly for insomnia. The facility did not have a system in place to monitor the effectiveness of the medication or care planned non-pharmacological approaches to promote sleep. R43 uses Trazadone and Melatonin for sleep. R43 does not have routine sleep monitoring, in relation to medication usage, or interventions to promote sleep in the care plan. This is evidenced by: Example 1 Surveyor reviewed R45's record and noted: R45 was admitted [DATE]. R45's admission Minimum Data set (MDS) dated [DATE] notes R45 understands, is understood and has cognitive impairment. R45 had behavioral symptoms of rejection of care and wandering and minimal symptoms of depression (02).…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-02-25 · tag F0895 — widespread
    Have a Compliance and Ethics Program.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop a compliance and ethics program that has been reasonably designed, implemented, and enforced so that it is likely to be effective in preventing and detecting criminal, civil, and administrative violations under the Act and promote quality of care. This has the potential to affect all 43 residents. Findings include: On 02/25/25, Surveyor reviewed the facility assessment dated [DATE] and revised on 02/20/24. The facility assessment does not include ethics and compliance training. On 02/25/25 at 2:00 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A and asked if the facility had an ethics and compliance program. NHA A stated she knew the facility needed a program, but due to other issues/priorities that arose, this was put aside and never implemented.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-02-25 · tag F0946 — widespread
    Provide training in compliance and ethics.
    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 set forth an effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program. This has the potential to affect all 43 residents. Findings include: On 02/25/25, Surveyor reviewed the facility assessment dated [DATE] and revised on 02/20/24. The facility assessment does not include ethics and compliance training. On 02/25/25, Surveyor reviewed three Certified Nursing Assistant (CNA) training records, and two licensed staff training records. CNA M, CNA N, CNA O, Registered Nurse (RN) H, Licensed Practical Nurse (LPN) K did not receive ethics and compliance training. On 02/25/25 at 2:00 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A and asked if the facility had an ethics and compliance program and how they effectively communicate the program's standards, policies, and procedures through a training program NHA A stated she…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-01-24 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility staff postings did not accurately reflect the census, or the actual hours worked by licensed and unlicensed staff on a daily basis. This has the potential to affect all 45 residents that reside in the facility. This is evidenced by: On entrance to the facility, Surveyor requested staff posting information. Review of staff postings from 12/21/23- 01/21/23 noted the census number listed on all sheets read 50. Surveyor was told the census was 45 during the entrance conference. Observation of the staff posting on 01/21/23, the day of entrance, revealed the posting indicated the census was 50. On 01/22/24 at 10:45 AM, Surveyor interviewed Scheduler M who completes the postings. Surveyor asked how Scheduler M completes the postings. Scheduler M relayed the following process. Scheduler M stated that she fills out the sheets every 2 weeks and posts them on the bulletin board. Scheduler M said the facility is licensed for 50 so that is what she puts as the census, and then looks at the number of hours that is scheduled for CNAs,…

    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.

    Nursing and Physician Services 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

$59,085 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $59,085 — penalty dated 2025-02-25
  • Medicare payment denial — starting 2025-03-15 for 6 days

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.

Who owns this facility

Owner / managerTypeRoleShareSince
GRAND VIEW HOME INC.Organization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 01/01/1966
BAUTCH, DORISIndividualCORPORATE DIRECTORsince 01/01/2020
BLAHA, GERALDINEIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 06/21/2023
MOEN, RODNEYIndividualCORPORATE DIRECTORsince 05/15/2012
SIMMONS, SHEILAIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 06/21/2023
SYVERSON, PAULIndividualCORPORATE DIRECTORsince 03/19/2025
VEHRENKAMP, JOHNIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2013
VONHADEN, ROBERTIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNFsince 01/01/2023
GONYO, THOMASIndividualCORPORATE OFFICERsince 10/18/2009
STEELE, LEAHIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/09/2023
KLOMPS-MCCLUNG, MEGANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2022
LUNSFORD, CHALSIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/28/2022

CMS files one row per role, so the 23 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$6.2M
Net patient revenuemost recent cost report
-12.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 67%Medicare 5%Other / private 28%

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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$415per resident / day
operating cost
$12,621per month
≈ monthly operating cost
$370per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WI

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525624. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, 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.

What to do next