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Congregational Home, Inc.

13900 W Burleigh Rd, Brookfield, WI 53005 · Non profit - Church related · 66 certified beds · (262) 781-0550 Medicare only — no Medicaid

Call the home — (262) 781-0550 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Feb 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score

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

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

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

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
13800 W North Ave · (414) 607-5280 · Call to confirm hours
Pharmacy
13950 W Capitol Dr · (414) 874-6200 · Call to confirm hours
Grocery
13340 Burlawn Pkwy · (414) 272-1759 · Call to confirm hours
Park
2865 Lilly Rd · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 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 increased26.7%16.1%15.4%worse
Long-stay residents who lose too much weight7.8%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder6.6%2.1%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.2%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 injury2.9%3.3%3.3%better
Long-stay residents whose ability to walk worsened17.2%18.4%16.1%typical
Long-stay residents on antianxiety or hypnotic medication10.6%16.9%18.9%better
Long-stay residents given the seasonal flu vaccine97.4%95.0%95.3%typical
Long-stay residents with pressure ulcers2.9%5.0%4.7%better
Long-stay residents with worsening bladder/bowel control27.3%24.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table3.1%15.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine96.4%82.2%79.4%better
Short-stay residents rehospitalized after admission26.2%23.1%22.6%worse
Short-stay residents with an outpatient ER visit8.5%15.5%12.0%better
Long-stay hospitalizations per 1,000 resident days0.651.661.67better
Long-stay outpatient ER visits per 1,000 resident days0.492.291.80better

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

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

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

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

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

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

65.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 263 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.3%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
59.5%U.S. median 56.6%
Met the expected recovery
0.72U.S. median 0.31
Therapy hours / resident / day
0.33hours / resident / day
Physical therapy
0.30hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 59.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 121 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.72 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 35% 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 SNF65.3%CMS range 59.4–70.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 6.8–12.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge59.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge51.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge56.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.2%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 discharge99.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened7.7%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 hospitalization5.8%CMS range 3.4–10.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.821.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.18
RN hours/ resident / day
0.88
LPN hours/ resident / day
4.30
Aide hours/ resident / day
6.36
Total nurse hours/ resident / day
0.73
RN hoursweekends
46.4%
Total nursing turnover
26.7%
RN turnover

How full it usually is: this home is certified for 66 beds and averages 59.6 residents a day — about 90% occupied, or roughly 6 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 6.36 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.18 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.30 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 5.87 hrs/resident/day on weekends vs 6.55 on weekdays — 10% thinner on weekends. RN hours go from 1.37 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 46% 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 (2025-07-31)
6
at the previous standard inspection (2024-05-01)

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.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · Gcited before2024-05-01 · 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 ensure residents at risk for pressure injuries, and with pressure injuries, were comprehensively assessed for the development of an individualized plan of care with interventions to promote healing, prevent infection and prevent new pressure injuries from forming. This was observed with 1 (R34) of 3 residents reviewed with pressure injuries and at risk for the development of pressure injuries. *R34 was assessed at high risk for the development of pressure injuries. Despite this, the facility did not initiate a turning or repositioning schedule for R34. On 11/7/23, R34 was noted to have developed a suspected deep tissue injury to the right heel. The facility did not individualize R34's care plan related to their pressure injury, conduct weekly wound assessments consistently or discuss risks versus benefits related to repositioning with R34 or R34's representative. Findings include: R34 was admitted to the facility on [DATE] with diagnoses of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-07-31 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: 61Number of residents cited:Based on observation, interview and record review, the facility did not ensure food was prepared, and served, in a sanitary manner. This was observed with the dish machine and the facility's 3 compartment sink which has the potential to affect all 61 Residents that reside at the facility.* The facility did not ensure the facility kitchen dish machine was functioning to sanitize dishware.*The facility did not ensure proper procedure for sanitization of dishes involving the 3-compartment sink.Findings include:The facility's Dish Machine policy and procedure dated 1/24/25 documents: . Dietary Supervisor will routinely log Dish Machine Temperatures to assure proper sanitizing of dishes in the Dish Machine Temp Log.1.Staff will monitor dish machine temperatures throughout the dishwashing process.2.Staff will record dish machine temperatures for the wash and rinse cycles at each meal.3.Staff will be trained to report any problem with the dish machine or…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-07-31 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled:8 of 12Number of residents cited:Based on interview and record review, the facility did not ensure admission and annual comprehensive Minimum Data Set (MDS) assessments were completed in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 8 (R38, R47, R48, R49, R53, R66, R79, and R91) of 12 residents reviewed for late MDS assessments.*R38's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.*R47's Annual MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.*R48's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.*R49's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.*R53's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-07-31 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled:6 of 12Number of residents cited:Based on interview and record review, the facility did not ensure admission, quarterly, and discharge Minimum Data Set (MDS) assessments were completed and transmitted in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 6 (R24, R47, R61, R79, R81, and R88) of 12 residents reviewed for late MDS assessments.*R24's Discharge Return Not Anticipated MDS assessment dated [DATE] was not completed or transmitted by the specified timeframe.*R47's Annual MDS assessment dated [DATE] was not transmitted by the specified timeframe.*R61's Quarterly MDS assessment dated [DATE] was not transmitted by the specified timeframe.*R79's admission MDS assessment dated [DATE] was not transmitted by the specified timeframe.*R81's Discharge Return Anticipated MDS assessment dated [DATE] was not completed or transmitted by the specified timeframe.*R88's Quarterly MDS assessment dated [DATE] was not transmitted by…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-31 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled:2 of 12Number of residents cited:Based on interview and record review, the facility did not ensure quarterly Minimum Data Set (MDS) assessments were completed in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 2 (R61 and R88) of 12 residents reviewed for late MDS assessments.*R61's Quarterly MDS assessment dated [DATE] was completed after the specified timeframe.*R88's Quarterly MDS assessment dated [DATE] was in progress and not completed by 7/4/2025 as specified in the RAI 3.0 User's Manual.Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2024 documents: The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (Assessment…

    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 before2025-07-31 · 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 Number of residents sampled:4Number of residents cited:1Based on interview and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R35) of 4 Residents reviewed for falls.*On 5/28/25, Certified Nursing Assistant (CNA)-N rolled R35 away from CNA-N during incontinence cares and R35 rolled off the bed and onto the floor. Findings Include:The facility's Safe Resident Handling, policy and procedure modified 8/21/19 documents: .F. If only one person assisting Resident should be rolled towards caregiver vs away from them. Call for extra assist as needed.R35 was admitted to the facility on [DATE] with diagnoses of Paroxysmal Atrial Fibrillation (Irregular, rapid heart rate that causes poor blood flow), Hypothyroidism (underactive thyroid), Essential Hypertension (chronic condition of persistently high blood pressure), Chronic Kidney Disease (progressive damage and loss of function in the kidneys), Chronic Respiratory Failure (long-term…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-05 · 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 interviews and record review, the facility did not ensure that 1 (R1) of 1 allegations of neglect were reported to the State Survey Agency within the required reporting timeframe. On 11/25/24, R1 and R1's spouse (Spouse-N) filed a grievance with Social Worker (SW)-D regarding a care concern that occurred on 11/22/25. The grievance was investigated, and the written results and plan were given to R1, and Spouse-N. On 11/28/24, Spouse-N sent an email to SW-D, during the Thanksgiving holiday weekend, stating that R1 and Spouse-N believes that the incident that occurred on 11/22/24 was neglectful and abusive. Facility staff did not report the allegation of neglect to the State Agency until 12/2/24, when SW-D returned from the holiday weekend. Findings include: The facility's policy dated 11/26/24, titled, Abuse, documents, in part: [Name of facility] prohibits mistreatment of residents including: . Neglect . Residents (and resident representatives) will be educated regarding their rights specific to…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 1 (R1) of 1 residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. R1 informed surveyor that R1 does not always receive help from facility staff to complete stretches/range of motion (ROM) exercises 2 times a day as indicated in R1's Certified Nursing Assistant (CNA) [NAME]. Facility staff do not document when stretches/ROM exercises are completed. R1 has a diagnosis of Multiple sclerosis with spasticity. R1 does not have a care plan with measurable goals and interventions related to spasticity and ROM. Findings include: The facility policy dated 2/22/24, entitled, ROM and/or Mobility, documents: Purpose/policy statement: Policy explanation and compliance guidelines: it is the policy of the [name of facility] to promote independence and quality of life by maintaining or improving a resident's quality of life. Policy: 1.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-05 · 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, record review, and interview, the facility did not ensure that 1 (R2) of 2 residents reviewed received adequate supervision and asssitive devices to prevent accidents. * R2 suffered falls that were not thoroughly investigated, with fall interventions and revisions to the fall care plan post fall review & IDT (interdisciplinary team) not implemented. Findings include: The facility's policy titled, Falls and modified 4/3/23 under Policy documents To follow the intent of HFS 132 and Federal regulations F323 sic (F689) Congregational Home will provide an environment that is free from hazards over which the facility has control and will provide appropriate supervision to each resident to prevent avoidable falls. Under Procedure documents 10. The Charge Nurse caring for the resident that has fallen will complete the following forms: * Skilled Nursing Fall Incident Form A note from appropriate licensed and direct care staff providing care to the resident prior to fall and any witnesses if…

    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 before2024-05-01 · 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, record review, and interview, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 serving kitchens. *Cook-J was observed preparing food for residents while not wearing a beard hair restraint. *Server- L was observed walking around the kitchen in areas where food is prepared for residents while not wearing a beard hair restraint. *Server-K was observed grabbing ready to eat food with gloved hands, after touching non-sanitized food surfaces, and placing the ready to eat food on plates for residents to eat. This deficient practice has the potential to affect 61 of 61 residents who eat and receive their meals from the main serving kitchen. Findings include: 1. Hair Restraints The facility's policy did not have a last revision date, and titled: Employee Sanitary Practices documents, Policy: All employees will: 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. On 04/29/2024 at 09:06 AM, during the initial…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-01 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility did not ensure that 1 (R59) of 15 residents reviewed had an individualized comprehensive plan of care. *R59 has bed canes on his bed and has a foley catheter. R59 did not have a comprehensive plan of care with individualized interventions to address the use of bed canes or a foley catheter. Findings Include: Surveyor reviewed the facility's Comprehensive Care Plan policy and procedure dated effective 3/15/18 and noted the following applicable documentation to R59 not having care plans in place for R59's foley catheter and the use of bed canes: .Policy: To develop and implement a comprehensive person-centered care plan for each Resident, consistent with Resident rights that include measurable outcomes and timeframes to meet a Resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Goal: Promote care for a Resident that will attain or maintain the Resident's highest practicable physical, mental…

    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
Show the remaining 10 citations
  • Potential for harm · Dcited before2024-05-01 · 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 observations, staff interview and record review, the facility did not ensure the environment remained as free of accident hazards as possible for 1(R 36) of 1 residents reviewed for falls. R36 fell in the facility on 3/29/24 and 4/22/24 from R36's recliner. R36's falls were not thoroughly investigated and R36's plan of care was not updated to prevent future falls with person-centered interventions. Findings Include: Surveyor reviewed the facility's Falls policy and procedure dated as modified 4/3/23 regarding R36's two falls and noted the following: Procedure: 1. Upon admission licensed nursing staff will complete the NSG Admit/Readmit Screener 2. Upon admission, quarterly, with a significant COC, licensed nursing staff will complete the 'Morse Fall Scale' form 3. Staff will review: .Cognitive skills .History of falls .Ambulation .Transfer ability .Medications .Diagnosis .And have the ability to add additional safety points if there is a condition or behavior which may escalate a Resident's safety risk…

    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 · D2024-05-01 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not have evidence that it attempted appropriate alternatives prior to installation of bed rails, did not have evidence it assessed residents at risk of entrapment from bed rails prior to installation, did not have evidence the risks and benefits of bed rails were discussed with the Resident and/or resident representatives and that informed consent was obtained prior to installation for 2 (R59 and R1) of 4 residents reviewed for repositioning bars. *R59 did not have a physician's order for the use of bed canes or a care plan in place for the use of bed assist bars. There is no documentation that the facility attempted to use appropriate alternatives prior to installing or using bed assist bars for R59. *R1 does not have an assessment that was updated quarterly that documented that the risks and benefits of bed rails were discussed with the Resident and/or Resident representatives and that informed consent was obtained prior to the installation of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-01 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 record review and interviews, the facility did not ensure hospice services providing end of life were coordinated for 1 (R59) of 1 sampled residents receiving hospice services. *R59 was admitted on hospice to the facility on 3/13/24. R59 did not have a physician certification of terminal illness and the facility did not designate a specific individual of the facility's interdisciplinary team to act as a liaison between the facility and the hospice provider. Findings Include: Surveyor reviewed the facility's hospice services policy and procedure dated effective 3/2/18 documents: PURPOSE/POLICY STATEMENT: It is the policy of the facility to have a coordinated plan of care for any Resident electing to utilize the Medicare hospice benefit. The plan of care will reflect the hospice philosophy as well as the individual's needs and living situation in the facility. STANDARD PRACTICE/PROCEDURE: 1. A Resident may use their Medicare hospice benefit when they have received a physician order for the services 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-03-29 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility did not ensure infection control prevention was implemented with hand hygiene. This was based on 1 (R17) of 1 handwashing observations. The facility did not establish an infection control water plan to prevent Legionella in the facility. This has the potential to effect all 53 residents in the facility. * The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Include water management team members who were knowledgeable about Legionella and the facility's water system. - Identify where control measures should be applied based on where Legionella could grow and spread - Identify acceptable ranges of control limits (temperature ranges) and corrective actions when control limits are not met - Include a process to confirm the WMP is being implemented and is effective * R17 had cares performed without hand hygiene to prevent spread of infection. Findings include: 1.) Surveyor reviewed the facility's…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-29 · tag F0656 — failed to write and follow a full care plan — pattern
    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, record review and staff interview, the facility did not develop and implement a comprehensive person-centered care plan for 3 (R24, R31, and R47) of 14 residents reviewed. -R24, R48 did not have a comprehensive plan of care related to the use of motion sensing alarms. -R31 did not have a comprehensive plan of care addressing the use of anticoagulant medication. -R47 did not have a comprehensive plan of care addressing the use of psychotropic medications. Findings include: The facility's policy and procedure entitled, Comprehensive Care Plan, dated 3/15/2018 was reviewed by Surveyor and documents in part, -The interdisciplinary team will develop and implement a person-centered comprehensive care plan to meet the resident's preferences and goals and address the resident's medical, physical, mental and psychosocial needs. - Using an assessment process to determine the resident's clinical condition, cognitive and functional status and use of services. - Establishing goals that have measurable…

    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 · E2023-03-29 · tag F0657 — failed to keep the care plan current — pattern
    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 7) R46 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Vascular Dementia without behavioral disturbance and Anxiety. R46's admission MDS (Minimum Data Set) assessment dated [DATE] indicates R46 receives antipsychotic, antidepressant and antianxiety medications on a daily basis. Surveyor reviewed R46's medical record. R46 was seen by psychiatric nurse practitioner on 1/19/23. Psychiatric nurse practitioner note dated 1/19/23 reads Seroquel 50 mg qd (every day). Surveyor notes an order implementation date of 1/10/23. Psychiatric nurse practitioner treatment recommendations dated 1/19/23 reads increase Seroquel (augement related to depression). Surveyor reviewed R46's January 2023 MAR (Medication Administration Record). R46's MAR reads Seroquel 75 mg qd for depression. Surveyor noted behavior monitoring on R46's January 2023 MAR for agitation. Surveyor noted there were no behaviors documented related to R46's agitation since admission to the facility on 1/10/23. Surveyor reviewed R46's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 4) R24's medical record was reviewed by Surveyor. A Fall Risk Assessment was conducted on 11/9/22, and 2/25/23, and indicates R24 is a high-risk for falls. R24 has a high risk for falls plan of care initiated 12/10/2022 with a Goal date of 6/13/2023 and revised on 3/21/2022. The interventions include: -5/18/2022 anticipate and meet R24's needs; call light in reach; educate about safety reminders and review post falls to determine root causes; follow facility fall protocol. -11/15/2022 transfer with a full body lift and 2 staff. -11/23/2022 encourage activity that promotes exercise; ensure appropriate footwear; goals can only be accomplished through directions of a skilled therapist in order to provide a safe environment to appropriately challenge resident without injury while providing significant resistance to create physiologic change; manual therapy; mobility per therapy direction; physical therapy evaluation; safety training; exercise/activity. R24's Progress Notes and Post Fall Reports included the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-29 · 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 residents received treatment and care in accordance with facility policy and procedure after unwitnessed falls for 2 (R50 and R19) of 6 residents reviewed for falls. R50 and R19 had multiple unwitnessed falls and were not neurologically assessed after the falls. Findings include: The facility policy and procedure entitled Falls dated 6/2/2017 states 9. When a resident fall [sic], the Charge Nurse and RN supervisor or Nurse Care Manager will be called to assess and provide immediate and ongoing direction. The RN supervisor or Nurse Care Manager will determine if the resident requires emergency evaluation at the hospital for assessment of the injury. 11. With head trauma the Charge Nurse will complete: -Evaluation if the resident will require further medical work up and be transported to the Hospital Emergency Room. -Head Trauma Craniotomy Check Flow Sheet will be initiated. The facility Head Trauma Craniotomy Check Flow Sheet, as referenced in the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-29 · 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, record review the facility did not ensure that residents received care consistent with professional standards of practice to prevent pressure injuries from developing for 1 (R2) of 2 residents reviewed for pressure injuries. * R2 did not have interventions in place to keep R2's heels offloaded while lying in R2's bed and sitting in R2's recliner chair. Surveyor had observations of R2's heels not being offloaded while lying in bed and sitting in recliner chair on several occasions during the survey. Findings include: The facility policy, entitled PRESSURE ULCER PREVENTION AND TREATMENT INTERVENTIONS GUIDELINES, updated on 6/15/2018, states: PROCEDURE: . B. Decreased Mobility, Activity or Sensory Perception . 3. Position the resident on bed pillows or other support devices. 5. Boney prominences susceptible to pressure will be protected. 7. Elevate heels off bed as indicated (e.g., place pillows under calf to raise heels off the bed or utilize foam heel boots, unless contraindicated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-29 · 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 interview and record review, the facility did not ensure that 2 (R46, R47) of 5 residents reviewed for unnecessary medications were free from unnecessary drugs. *R46 had orders for antipsychotic medication and did not have documented targeted behaviors or specific indication for use of the antipsychotic medication in their medical record. R46 had an inappropriate diagnosis for usage of antipsychotic medication. *R47 had orders for a psychotropic medication and did not have specific documented targeted behavior monitoring and/or specific reasons for use of the medication in their medical records. Findings include: *R46 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Vascular Dementia without behavioral disturbance and Anxiety. R46's admission MDS (Minimum Data Set) assessment dated [DATE] indicates R46 receives antipsychotic, antidepressant and antianxiety medications on a daily basis. Surveyor reviewed R46's medical record. R46 was seen by psychiatric nurse practitioner on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
BOYD, MAHLONIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2023
COLLIS, HARRYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2021
CUMMINGS, WILLIAMIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2020
GRIFFITH, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2020
GUSZKOWSKI, EUGENEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2020
HARMON, KEITHIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2023
HARRIS, JAMESIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2024
HENRY, PETERIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2021
MAUER, LISAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2019
MESSNICK, EILEENIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2019
RUSS, STEVENIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2021
SCHLOEMER, NATHANIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2021
STOCK, THOMASIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2023
YORK, CHARLESIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/01/2022
SERVAIS, PATRICIAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/03/2020
SPRTEL, KRISTINEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/10/2017
BAIRD TRUST COMPANYOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/24/2023
GREENFIELD REHABILITATION AGENCY, INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2019
BERG, TINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/19/2018
CRAWFORD, CARRIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/18/2023
FORD, FELICIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/24/2023
JEFFERSON, LARONDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/31/2023
KEHOSS, ANMARIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/21/2017
KRAUSS, ANGELAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/03/2012
LAMONTE, STEPHENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/21/2017
OSELL, GINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/21/2017
SCHMITT, ELLENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2025
SOLAKIAN, CATHERINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/23/2017
ZOVI, MAURICEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/22/2013
SVA CERTIFIED PUBLIC ACCOUNTANTS, S.C.OrganizationADP OF THE SNFsince 11/01/2015

CMS files one row per role, so the 60 rows in the source record cover these 30 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 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.

$15.6M
Net patient revenuemost recent cost report
-2.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 18%Other / private 82%

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

$729per resident / day
operating cost
$22,155per month
≈ monthly operating cost
$712per 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

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Wisconsin Medicaid page for homes that do.

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 525700. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-31, 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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