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Greentree Health and Rehabilitation Center

70 Greentree Rd, Clintonville, WI 54929 · For profit - Corporation · 50 certified beds · (715) 823-2194 Medicare & Medicaid certified

Call the home — (715) 823-2194 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609, F0610) — most recent Oct 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
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
100 County Road B · (715) 524-2161 · Call to confirm hours
Pharmacy
201 S Main St · (715) 823-4238 · Call to confirm hours
Grocery
29 S Main St · (715) 460-3396 · Call to confirm hours
Park
(715) 823-7660 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

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

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.7%16.1%15.4%better
Long-stay residents who lose too much weight9.3%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder0.9%2.1%0.9%typical
Long-stay residents with a urinary tract infection1.7%2.7%2.0%better
Long-stay residents with depressive symptoms16.8%5.7%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.8%3.3%3.3%better
Long-stay residents whose ability to walk worsened13.7%18.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication28.0%16.9%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers1.9%5.0%4.7%better
Long-stay residents with worsening bladder/bowel control32.8%24.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.9%15.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine84.4%82.2%79.4%typical
Short-stay residents rehospitalized after admission26.0%23.1%22.6%worse
Short-stay residents with an outpatient ER visit18.5%15.5%12.0%worse

§ 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.

53.5% 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.

53.5%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
38.1%U.S. median 56.6%
Met the expected recovery
0.60U.S. median 0.31
Therapy hours / resident / day
0.34hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 38.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 21 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.60 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF53.5%CMS range 37.8–67.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 6.3–15.010.7%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 discharge38.1%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 discharge38.1%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 discharge33.3%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 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 stay4.0%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 worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 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

0.85
RN hours/ resident / day
0.62
LPN hours/ resident / day
2.15
Aide hours/ resident / day
3.62
Total nurse hours/ resident / day
0.47
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 50 beds and averages 37.0 residents a day — about 74% occupied, or roughly 13 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.05 hrs/resident/day on weekends vs 3.85 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.00 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

12
deficiencies at the latest standard inspection (2025-04-23)
1
at the previous standard inspection (2024-02-21)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Actual harm · Gcited before2025-04-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R86) of 1 sampled resident was transferred appropriately and in accordance with the facility's policy. On 4/5/25, Certified Nursing Assistant (CNA)-K transferred R86 without a gait belt. R86 fell during the transfer and sustained a head injury that required 3 staples. Findings include: The facility's Safe Resident Handling/Transfers Policy, revised 12/2024, indicates: It is the policy of this facility to ensure residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping employees safe in accordance with current standards and guidelines .All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them .Compliance Guidelines: 1. The Interdisciplinary Team (IDT) or designee will evaluate and assess each resident's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-09 · 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 staff interview, record review, and policy review, the facility failed to timely report an allegation of physical abuse for 2 residents (R) (R1 and R2) of 3 sampled residents. On 7/24/25 at approximately 6:30 AM, R1 put R1's arms around R2's neck, pulled R2 toward R1, and pinched R2's ear. Staff stated R2 appeared upset and did not want the interaction to occur. Staff did not report the abuse until another incident occurred that afternoon. Findings include:Review of the facility's Abuse Prevention policy, dated 7/2024, indicated it is the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers,…

    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 · D2025-10-09 · tag F0646 — isolated
    Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II referral was completed after a significant change in mental status for 1 resident (R) (R1) of 1 resident reviewed. A psychiatric evaluation on 7/23/25 indicated R1 had self-injurious behaviors and hit/pinched others. The evaluation contained recommendations to increase R1's divalproex (anticonvulsant medication) and quetiapine (antipsychotic medication). A PASARR Level II referral was not completed.Findings include:Review of the facility's Resident Assessment - Coordination with PASARR Program policy, dated 7/24, revealed the facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. Any Level II resident who experiences a…

    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 · E2025-04-23 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 39 residents residing in the facility. Enhanced Barrier precautions (EBP) were not implemented for R187 who had an indwelling urinary catheter. Staff did not complete appropriate hand hygiene after providing care for R6. Residents were not offered hand hygiene prior to the lunch meal on 4/22/25. Finding includes: The facility's ICPC Standard and Transmission-Based Precautions (TBP) policy, dated 2/2025, indicates: .Enhanced Barrier Precautions (EBP): Expand the use of personal protective equipment (PPE) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of multidrug-resistant organisms (MDROs) to staffs' hands and clothing then indirectly…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-23 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff and resident interview, and record, review, the facility did not maintain dignity for 3 residents (R) (R20, R11, and R6) of 23 sampled residents. R20 required feeding assistance. On 4/22/25, R20 watched other residents eat in the dining room and waited 16 minutes for assistance. In addition, staff in the dining room did not address or speak to R20. R11 and R6 required feeding assistance. On 4/22/25, staff in the dining room did not speak to R11 and R6 while feeding them. Findings include: The facility's Meal, Preparing Resident for policy, dated 5/2024, indicates: It is the policy of this facility that the primary purpose of preparing the resident for a meal is to serve the meal in a pleasant environment and to make the mealtime a pleasant event. Encourage residents to eat in the dining area. This provides each resident with an opportunity to socialize and make new friends . The facility's Dietary Support Personnel, Sufficient policy, dated 1/2022, indicates: .Sufficient support personnel means having enough dietary and food nutrition staff to safely…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-23 · tag F0551 — isolated
    Give the resident's representative the ability to exercise the resident's rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure court-ordered protective placement was obtained for 1 resident (R) (R9) of 2 sampled residents. R9 was under Guardianship. The facility did not ensure court-ordered protective placement in the least restrictive environment was obtained after R9's nursing home stay exceeded 60 days. Findings include: From 4/21/25 to 4/23/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including schizophrenia, epilepsy, and major depressive disorder. R9's Minimum Data Set (MDS) assessment, dated 1/15/25, had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R9 was unable to complete the interview. R9 had a Guardianship that was activated on 9/29/21. R9's medical record contained a petition for protective placement that was dated 8/22/24. On 4/23/25 at 9:12 AM, Surveyor reviewed R9's medical record with Social Worker (SW)-P who confirmed the petition for protective placement…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-23 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not make a prompt effort to investigate and resolve a grievance for 1 resident (R) (R5) of 1 sampled resident. R5 voiced a concern to staff and the Grievance Official that another resident repeatedly woke R5 up in the early morning hours. R5's grievance was not documented, thoroughly investigated, or resolved. Findings include: The facility's Resident and Family Grievances Policy, revised 12/2024, indicates: It is the policy of this facility to support each resident's .right to voice grievances without discrimination or fear of reprisal .Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of the complaint/grievance .1. The Social Worker has been designated as the Grievance Official. 2. The Grievance Official is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-23 · 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 staff interview and record review, the facility did not ensure an injury of unknown origin was reported to the State Agency (SA) for 1 resident (R) (R32) of 4 sampled residents. On 4/2/25, staff discovered a hematoma on R32's left forearm. Facility staff and Hospice staff were unsure how the injury occurred. The facility did not report the injury of unknown origin to the SA. Findings include: The facility's Abuse Prevention policy and procedure, updated 7/2024, indicates: Identification of abuse - Identify events, such as but not limited to suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. All alleged violations will be reported via phone or in writing within 2 hours to the State Licensing Agency. The facility shall follow up with the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days . From 4/21/25 to 4/23/25, Surveyor reviewed R32's medical…

    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 · D2025-04-23 · 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 staff interview and record review, the facility did not ensure an injury of unknown origin was thoroughly investigated for 1 resident (R) (R32) of 4 sampled residents. R32 had an injury of unknown origin that was discovered on 4/2/25. The facility did not interview other residents to rule out abuse during the investigation. Findings include: The facility's Abuse Prevention policy and procedure, updated 7/2024, indicates: Identification of abuse - Identify events, such as but not limited to suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. The investigation shall consist of: .6. Interviews with other residents to whom the accused employee provides care or services. From 4/21/25 to 4/23/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] and had diagnoses including dementia, adult failure to thrive, and palliative care. R32's admission Minimum Data Set (MDS) 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-23 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not revise a care plans in accordance with current care needs for 1 resident (R) (R32) of 15 sampled residents. R32's care plan was not updated to include calling R32 by R32's preferred names. R32's care plan was also not updated when R32 incurred an injury of unknown origin and geri-sleeves were implemented to protect R32's skin. Findings include: From 4/21/25 to 4/23/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] and had diagnoses including dementia, adult failure to thrive, and palliative care. R32's admission Minimum Data Set (MDS) assessment, dated 2/5/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R32 had severely impaired cognition. R32 had an activated Power of Attorney for Healthcare (POAHC). On 4/21/25 at 1:15 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who indicated when R32 was first admitted , staff called R32 by a shortened version of R32'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 · D2025-04-23 · 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, staff interview, and record review, the facility did not ensure 3 residents (R) (R7, R12, and R186) of 17 sampled residents received assistance as needed to complete activities of daily living (ADLs). R7 did not receive assistance with positioning, toileting, and breakfast. R12 did not receive weekly showers. In addition, the facility did not address R12's request for more showers. R186 did not receive a shower while at the facility. Findings include: The facility's Activities of Daily Living (ADLs) policy, dated 12/2024, indicates: Care and services will be provided for the following ADLs: 1. Bathing, dressing, grooming, and oral care; 2. Transfer and ambulation; 3. Toileting; 4. Eating to include meals and snacks .3. A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .5. The facility will maintain individual objectives of the care plan. The facility's Resident Showers policy, dated 12/2024,…

    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 11 citations
  • Potential for harm · D2025-04-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 2 residents (R) (R23 and R189) of 3 sampled residents. On 4/22/25, staff administered R23's AM and noon medications more than an hour after the scheduled times. On 4/22/25, staff left R189's medications at the bedside for R189 to self-administer. R189 did not have a physician order to self-administer medication or a self-administration of medication assessment that indicated R189 could safely and accurately self-administer medication. Findings include: The facility's undated Medication Administration-General Guidelines policy indicates: Medications are administered as prescribed in accordance with good nursing principles and practices .Administration: .k. Medications are administered in accordance with written orders of the attending physician .o. Medications are only administered after the 5 rights have been reviewed .4) right time; .r.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-23 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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 staff interview and record review, the facility did not monitor for adverse reactions of a high-risk medication for 1 resident (R) (R86) of 5 sampled residents. R86 was prescribed gabapentin (an anticonvulsant medication). The facility did not monitor for adverse reactions or side effects of the high-risk medication. Findings include: Per medlineplus.gov, potential side effects of gabapentin include: Loss of balance or coordination, double vision, blurred vision, uncontrollable movements of the eyes, difficulty thinking or concentrating, difficulty speaking, headache, drowsiness, dizziness, diarrhea, constipation, loss of appetite, weight loss, nausea, vomiting, and uncontrollable shaking of a part of the body. Some side effects can be serious such as swelling of the face, throat, tongue, lips, and eyes, difficulty swallowing or breathing, hoarseness and seizures . On 4/21/25, Surveyor reviewed R86's medical record. R86 was admitted to the facility on [DATE] and had diagnoses including hemiplegia 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-23 · 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 staff interview and record review, the facility did not ensure 1 resident (R) (R187) of 5 sampled residents was monitored for adverse reactions to psychotropic medication. R187 had an order for paliperidone (an antipsychotic medication). R187's medical record did not contain an Abnormal Involuntary Movement Scale (AIMS) assessment (a rating scale designed to measure involuntary movements known as tardive dyskinesia which is a disorder that can develop as a side-effect of long-term treatment with antipsychotic medication) for the use of paliperidone. Findings include: The facility's Use of Psychotropic Medication(s) policy, dated 12/2024, indicates: .1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, antianxiety, and hypnotics .13. Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS)…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-11 · 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 staff interview and record review, the facility did not ensure an allegation of neglect was reported to the State Agency (SA) for 1 resident (R) (R1) of 3 sampled residents. On 7/18/24, R1 had a fall with major injury. R1's care plan contained an intervention for a sensor alarm on R1's bed. The facility's fall investigation indicated a sensor alarm was not on R1's bed at the time of the fall. The facility did not report the potential neglect to the SA. Findings include: The facility's Abuse Prevention policy, with a revision date of July 2024, indicates: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .Identification of Abuse - Identify events, such as but not limited to, suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. 1. Bruises, skin tears and injuries of unknown source will be investigated to rule…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-11 · 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 staff interview and record review, the facility did not ensure the provision of an assistive device to prevent accidents for 1 resident (R) (R1) of 3 sampled residents. R1's plan of care contained an intervention for a sensor alarm on R1's bed. On 7/18/24 at 3:45 AM, R1 sustained a fall with injury. The sensor alarm was not in place at the time of the fall. Findings include: The facility's Falls Program policy, revised 9/2024, indicates: It is the policy of this facility to reduce the number and severity of falls and to identify high risk residents and take precautionary measures .Falls Interdisciplinary Team (IDT): .2. When a fall occurs, the Falls IDT will meet the next business day to discuss the fall, interventions, and review risk management. A Fall IDT note will be made regarding the fall. Risk Management will be left open for 7 days with the IDT to re-evaluate effectiveness of interventions. A closing Fall IDT note will be completed after 7 days. The Director of Nursing (DON) and the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-21 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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 staff interview and record review, the facility did not ensure monitoring of high-risk medications for 1 Resident (R) (R140) of 5 sampled residents. The facility did not monitor R140 for adverse effects of anticoagulant, antidepressant, and diuretic medication. Findings include: MEDSCAPE (a web based medical resource [DATE]) identifies warfarin as an anticoagulant medication that reduces the formation of blood clots in veins or arteries, which can reduce the risk of stroke, heart attack or other serious conditions. Adverse reactions/side effects include: hemorrhage (bleeding), intraocular hemorrhage, abdominal pain, flatulence, alopecia (hair loss), rash, pruritus (itching), taste disturbance, tissue necrosis, headache, lethargy, dizziness, anemia, hepatitis, respiratory tract bleeding, hypersensitivity reaction, blood dyscrasias (disease or disorders of blood), fever, purple toe syndrome, and increased fracture risk with long-term usage. MEDSCAPE identifies sertraline as an antidepressant medication…

    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 · F2023-02-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and record review, the facility did not ensure food was handled, stored and prepared in a sanitary manner. The practice had the potential to affect 39 of 39 residents. The facility did not monitor and document food holding and food cooling temperatures. The facility did not ensure food was stored in a clean, dry location not exposed to splash, dust or contamination. The facility did not have a working handwashing sink separate from sinks used for food prep, warewashing and eye washing. Dietary staff did not wait two minutes to take microwave reheated food temperatures to ensure food was heated evenly. Findings include: During an initial tour of the kitchen on 2/13/23 at 9:00 AM, Dietary Director (DD)-D was unsure what food code the facility used as a standard of practice. On 2/13/23 at 11:15 AM, Surveyor interviewed Dietary Aide (DA)-G who was also unsure what food code the facility used as a standard of practice. On 2/15/23 at 9:37 AM, Surveyor interviewed Nursing Home Administrator Consultant (NHAC)-C who stated the facility did not have…

    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 · D2023-02-15 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and staff interview, the facility did not ensure privacy was maintained for 3 Residents (R) (R16, R28 and R29) of 4 residents reviewed for privacy. R16's room contained a monitor with video and audio capabilities brought in by R16's roommate's (R28) health care decision maker. The monitor was installed in the shared room without R16's knowledge or consent. R28's room contained a monitor with video and audio capabilities. R28's medical record did not contain a signed consent for the monitor to be placed in R28's room. R29's room contained a monitor with video and audio capabilities brought in by R29's roommate's (R8) Power of Attorney (POA). The monitor was installed in the shared room without R29's knowledge or consent. Findings include: The facility's Use of Electronic Monitoring Equipment in Resident Rooms document dated 7/10/2019, contained the following information: The facility is committed to the promotion of the safety of residents and to the maintenance of an environment conductive to the delivery of quality healthcare while preserving 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-15 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility did not implement its written policies and procedures to ensure 1 (Licensed Practical Nurse (LPN)-L) of 8 staff had a thorough background check completed every four years. LPN-L was hired on 6/1/14. The facility was not able to provide proof LPN-L had Department of Justice (DOJ) or Integrated Background Information System (IBIS) letters completed within the past four years as required. Findings include: The Wisconsin Caregiver Program Manual for Entities Regulated by the Division of Quality Assurance (P-00038 updated 2/2016) states, After the initial background check at the time of employment or contracting, entities must conduct new caregiver background checks at least every four years or at any time within that period that an entity has reason to believe new checks should be obtained. Surveyor reviewed facility's Abuse: Prevention and Prohibition Against policy contained the following information: Screening: 2. The Facility will not hire or retain any person, directly or indirectly who: ~Has been found guilty of 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 · D2023-02-15 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and resident, family and staff interview, the facility did not ensure 1 Resident (R) (R13) of 2 residents reviewed received assistance with arrangements for an audiology (ear doctor) appointment to obtain hearing aids. The facility did not assist R13 with scheduling an audiology appointment in order to obtain hearing aids. Findings include: From 2/13/23 through 2/15/23, Surveyor reviewed R13's medical record. R13 was responsible for R13's own decision making. R13's Minimum Data Set (MDS) assessment, dated 11/22/22, contained a Brief Interview for Mental Status (BIMS) score of 15 which indicated R13 had intact cognition. R13's medical record indicated R13's last audiology appointment was on 8/12/21. On 2/13/23 at 1:19 PM, Surveyor interviewed R13. R13 stated R13 did not have hearing aids and wanted hearing aids. Surveyor noted R13 was unable to hear adequately and repeatedly asked Surveyor to repeat questions. R13 was only able to hear adequately when Surveyor was close to R13 and increased the volume of Surveyor's voice. On 2/14/23 at 1:16 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 · D2023-02-15 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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, resident and staff interview and record review, the facility did not ensure food accommodations were made for 2 Residents (R) (R190 and R14) of 2 residents with food allergies or intolerances. R190's medical record documented R190 was allergic to egg whites. R190's meal ticket did not contain the allergy and R190 was served eggs on multiple occasions. R14's medical record documented R14 was allergic to pineapple. R14's meal ticket did not contain the allergy. Findings include: Wisconsin Food code 2022 documents at section 3-101.11 Safe, Unadulterated, and Honestly Presented. food shall be safe, unadulterated, and, as specified under § 3-601.12, honestly presented. Note: The following common ingredients may cause allergic reactions: eggs (albumen, whites, meringue); Milk and Milk Products (Whey, Nonfat Dry Milk, Casein, Sodium Caseinate etc.); Peanuts (peanut butter, unrefined peanut oil, and flour); Wheat & Wheat Proteins (malt, caramel color, flour); Tree Nuts (almonds, walnuts, pecans,…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.2-0.2 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 3 of 52.7+0.3 vs chain
Quality measures 3 of 54.4-1.4 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare And Rehabilitation - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Northgate PlazaIrving, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA

Showing 40 of 341; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleSince
BURNAM, SOONIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 01/01/2022
KAMIN, SHAYNAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/27/2025
NEAS, MARISSAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2014
PORT, BARRYIndividualCORPORATE DIRECTORsince 01/01/2022
KEETCH, CHADIndividualCORPORATE OFFICERsince 03/01/2011
J THOMPSON STAFFING INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 06/01/2014
PRN HEALTH SERVICES, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 06/01/2014
DEER CREEK HEALTH HOLDINGS LLCOrganizationADP OF THE SNFsince 01/01/2022
ENSIGN SERVICES INCOrganizationADP OF THE SNFsince 01/01/2022
STANDARD BEARER HEALTHCARE OP, LPOrganizationADP OF THE SNFsince 01/01/2022
THE ENSIGN GROUP INCOrganizationADP OF THE SNFsince 01/01/2022

CMS files one row per role, so the 16 rows in the source record cover these 11 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.

6 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.

$4.4M
Net patient revenuemost recent cost report
+5.9%
Operating marginrevenue minus expenses
$416K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 56%Medicare 4%Other / private 40%

This home reported $416K paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$303per resident / day
operating cost
$9,213per month
≈ monthly operating cost
$322per day
avg. revenue, all payers

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

What families pay in WI

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525348. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-23, 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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