Care And Rehab - Cumberland
1100 7th Ave, Cumberland, WI 54829 · For profit - Corporation · 50 certified beds · (715) 822-7050 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, 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 (23) — 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
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 3 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 25.6% | 16.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.5% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.4% | 2.1% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.8% | 2.7% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 11.0% | 5.7% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.4% | 3.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 21.9% | 18.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.6% | 16.9% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.2% | 5.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.0% | 24.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.5% | 15.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 89.1% | 82.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 30.6% | 23.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 28.3% | 15.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.00 | 1.66 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.26 | 2.29 | 1.80 | worse |
‡ 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.
49.6% 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 44 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.4% 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 42 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 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 49.6%CMS range 37.5–62.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.6%CMS range 5.1–15.0 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 52.4% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 61.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 47.6% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 98.2% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.4%CMS range 5.0–17.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 50 beds and averages 39.5 residents a day — about 79% occupied, or roughly 10 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 4.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.93 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.08 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 4.09 hrs/resident/day on weekends vs 4.76 on weekdays — 14% thinner on weekends. RN hours go from 1.05 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · G2026-02-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that 1 of 3 residents (R) reviewed for pressure injuries (PI) (R32) received care consistently with professional standards of practice to prevent further deterioration and promote healing of an existing PI. R32 was at risk for PI development. The facility failed to provide adequate and consistent wound care treatments, did not complete comprehensive weekly assessment, and did not notify provider of new PI.Findings include: R32 was admitted to the facility on [DATE] with diagnoses including in part, atrial fibrillation, nonrheumatic aortic insufficiency, hypertensive heart disease, peripheral vascular disease, unilateral osteoarthritis left ankle and foot, hypertension, weakness, and presence of right artificial hip joint.R32's Minimum Data Set (MDS) assessment, dated 12/13/25, identified R32 required substantial maximal assistance for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-18 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 must ensure each resident is free from unnecessary medications as evidenced by completing adequate behavioral monitoring for 2 of 5 residents (R7 and R16) reviewed for unnecessary medications.Findings:Facility policy titled, PSYCHOTOPIC MEDICATIONS, revised 1/26, stated in part: 6. The specific targeted behaviors for which the drug is being administered will be entered by the nurse on the behavior monitoring record. The effectiveness of the psychotropic drug will be documented on the behavior sheet each shift. Total occurrences may be based on the personal observation or the observation of other staff members 8. The effectiveness of the psychotropic drug on the targeted behavior will be addressed at least monthly in the interdisciplinary notes .10. The behavior monitoring record will be reviewed quarterly . Example 1R7 was admitted on [DATE] with a Brief Interview of Mental Status (BIMS) score of 14/15 which indicated R7 was cognitively intact. R7 had diagnoses…
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.
- Potential for harm · D2026-02-18 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 provide the proper discharge documentation for 2 of 2 residents (R44 and R4) reviewed for discharge.Facility did not have bed hold or notice of transfer documentation for R44.Facility did not have Ombudsman notification and notice of transfer documentation for R4.Findings:Example 1R44 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) of 13/15, which indicated R44 was cognitively intact. R44 had Minimum Data Set (MDS) stating 'Discharge Return Anticipated' dated on 01/14/26 and 12/21/25.On 02/18/26 at 9:13 AM, Surveyor was unable to find a bed hold for discharge date of 01/14/26 and a notice of transfer form. Surveyor asked Director of Nursing (DON) B for these documents.On 02/18/26 at 9:43 AM, DON B came into the conference room asking Surveyor what needs to be on the 'Notice of Transfer.' Surveyor informed DON B, The Notice of Transfer needs to have 1) in writing, 2) in language they understand, 3) the reason for the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-18 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not conduct a Preadmission Screening Resident Review (PASRR) Level II screen for R1, who has a serious mental disorder and is taking psychotropic medication to treat symptoms of major mental disorder to ensure he received care and services to meet his needs. The facility practice affected 1 of 1 resident (R) reviewed (R1).Findings include:Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that Medicaid-certified nursing facilities:Evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID)Offered all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings)Provide all applicants the services they need in those settingsPASRR screenings determine whether applicants might have an intellectual/developmental disability (ID/DD) and/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.
- Potential for harm · Dcited before2026-02-18 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 interview and record review, the facility did not develop and implement a person-centered care plan for a resident consistent with resident rights including services to attain or maintain the resident's highest or practicable physical, mental or psychosocial needs for 1 of 5 residents (R5). R5 did not have a comprehensive person-centered care plan for the use of a high-risk medications of Apixaban, which is an anticoagulant, Furosemide, which is a diuretic, and Lantus subcutaneous solution, which is an insulin. Findings include:Facility policy titled, Care Planning, revised 12/25, states in part, See AMDA guidelines. American Medical Directors Association (AMDA) guidelines states in part, Care Plan .Interventions: Specific, actionable steps for nursing staff, including monitoring, non-pharmacological interventions, and pharmacological management.R5 was admitted on [DATE]. R5's diagnosis included diabetes mellitus with chronic kidney disease, atrial fibrillation, congestive heart failure, obstructive 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.
- Potential for harm · Dcited before2026-02-18 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 interview and record review, the facility did not ensure care plan was revised to reflect resident's current needs and direct staff in providing necessary care and services. The facility practice affected 1 of 15 residents' care plans reviewed (R5).R5 had changes in mood and increased depression. R5's care plan was not updated to reflect changes identified, interventions, and monitoring of R5. Findings include:According to the Resident Assessment Instrument, The comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving.R5 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes mellitus, chronic kidney diseases, prostate cancer,…
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.
- Potential for harm · D2026-02-18 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure 1 (R32) of 1 resident reviewed receiving physical therapy received the care necessary to meet professional standards.Facility did not obtain a Cam boot for R32's transfers as ordered from Orthopedic Surgeon I.Findings include:R32 was admitted to the facility on [DATE] with diagnoses including in part, atrial fibrillation, nonrheumatic aortic insufficiency, hypertensive heart disease, peripheral vascular disease, unilateral osteoarthritis left ankle and foot, hypertension, weakness, and presence of right artificial hip joint.R32's Minimum Data Set (MDS) assessment, dated 12/13/25, identified R32 required substantial maximal assistance for bed mobility, taking on and off footwear, rolling left to right, sitting to lying, chair to bed, toileting, and for transfers.Surveyor reviewed R32's ortho notes, which stated in part, .-On 02/10/26, Left tibia/fibula fractureMay remove temp splint and transition to tall Cam walking boot. May remove…
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.
- Potential for harm · Dcited before2026-02-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure residents were safe in their environment to prevent the risk of falling. This occurred for 1 of 1 resident (R) reviewed for falls, (R16). The facility staff did not ensure R16 had dycem pad while R16 was sitting in recliner as care planned.Findings include: R16 was admitted to the facility on [DATE] with diagnoses including in part, type 2 diabetes mellitus with hyperglycemia, hypertensive kidney disease stage 1-4, Alzheimer's disease, benign neoplasm of cerebral meninges, nonrheumatic aortic stenosis, dementia, personal history of MRSA, and muscle weakness. R16's Minimum Data Set (MDS) assessment, dated 11/06/25, identified R16 had Brief Interview for Mental Status (BIMS) of 10/15 that identified R16 with moderate cognitive impairment. R16's fall risk care plan stated, R16 is at risk for falls r/t disease process, dementia initiated on 09/26/2023: Be sure the resident's call light is within reach and encourage the resident to use it…
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.
- Potential for harm · D2026-02-18 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infection, for 2 out of 13 residents (R) (R2 and R4) reviewed. R2 and R4 have indwelling medical devices and were not on Enhanced Barrier Precautions (EBP). Licensed Practical Nurse (LPN) H did not perform hand hygiene during water flush for R4's peg tube. Findings include: The facility's policy titled, Infection Prevention and Control Manual Enhanced Barrier Precautions (EBP)reads in part, .The purpose of Enhanced Barrier Precautions is to prevent opportunities for transfer of Multidrug-Resistant Organisms (MDROs) to employee's hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or body fluids. High-contact resident care activities include Dressing, bathing/showering, transferring, providing…
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.
- Potential for harm · D2026-02-18 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) which must include, at a minimum, an antibiotic stewardship program with a system to monitor antibiotic use. This had the potential to affect 1 of 5 residents (R7) reviewed for unnecessary medications.Hospice placed R7 on Cephalexin 500mg oral to be given two times a day for a UTI, which was not diagnosed with a urinalysis (U/A) and a culture and sensitivity (C & S). Facility did not ensure the antibiotic stewardship program was followed and that the criteria used to identify infection, McGeer's, was followed.Findings:Facility policy titled, Antibiotic Stewardship Policy, copy with permission dated 2023 stated in part: .Procedure: .2. The Nurse will utilize the (insert facility identified/approved standardized criteria tools: i.e. Loeb Minimum Criteria, McGeer Constitutional Criteria, AHRQ-UTI SBAR, etc.) infection criteria protocol to assess/evaluate resident to determine if it is necessary 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.
- Potential for harm · D2025-09-18 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond 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 upon interview and policy review, the facility did not ensure a thorough investigation for 1 of 1 (R1) resident reviewed for safety concerns.R1 fell during an assist of 1 transfer with Certified Nursing Assistant (CNA) C without proper safety measures in place. Facility did not complete a thorough investigation when they did not interview or investigate for potential risk to other residents throughout the facility.This is evidenced by:The facility's policy and procedure for Abuse Prevention, last reviewed 05/2025, includes, in part: .The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The purpose of the policy is to use a systematic approach to the creating of a climate which encourages the protection of the right to be free from abuse. This will be done by:* 6. A thorough investigation of 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.
Show the remaining 12 citations
- Potential for harm · E2025-07-07 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility did not ensure controlled medications were administered under professional standards of clinical practices for residents (R1, R2, R3, R4, and R5). R1, R2, R3, and R4 had narcotic medications, in which the facility did not ensure accurate documentation on the narcotic sheets. R5 has Lorazepam, which is a controlled substance, needing a double lock. The medication was not double locked. Findings include: On 07/07/25 at 12:25 PM, Surveyor observed medication cart on 200-300 hall with Registered Nurse (RN) C. Surveyor observed R1, R2, R3 and R4's narcotic sheets to have discrepancies. Surveyor reviewed R1's narcotic sheet for Morphine Concentrate 20mg/ml 15 ml bottle, take 10mg (0.5ml) by mouth every 4 hours as needed for shortness of breath or pain. R1's narcotic sheet was signed with start volume of 15 ml. -On 04/05/25 at 5:09 PM, signed out on narcotic sheet 0.5ml used. No documentation in R1's Medication Administration Record (MAR) that R1 received the narcotic. -On 04/09/25 at 12:05 PM, signed out on narcotic sheet 0.5ml used. No…
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.
- Potential for harm · D2024-11-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 interview and record review, the facility did not ensure that based on the comprehensive assessment of a resident, that residents receive treatment and care in accordance with professional standards of practice. The facility did not ensure that a Registered Nurse (RN) assessed a resident after a fall occurred. This had the potential to effect 2 of 7 residents (R) (R29, R193) investigated for accidents. Findings include: Wisconsin state statue Chapter N 6 titled Standards Of Practice For Registered Nurses And Licensed Practical Nurses dated December 2018, states, In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider: (a) Accept only patient care assignments which the L.P.N. is competent to perform. (b) Provide basic nursing care. N 6.04(1)(c)(c) Record nursing care given and report to the appropriate person changes in the condition of a patient. (d) Consult with a provider in cases where an L.P.N. knows or should…
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.
- Potential for harm · Dcited before2024-11-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure new care planned fall interventions were implemented post falls to prevent accidents for 1 of 7 residents (R) R29, reviewed for falls. The facility did not implement fall interventions or identify root cause for ten fall incidents, of which R29 sustained minor injury. Findings: The facility's policy titled, Fall/Incident Assessment, read in part .PURPOSE: To assure appropriate follow-through on all accidents and incidents; and to give guidance on preventive/corrective action. 8. The nurse will assess/evaluate the need for any changes in safety precautions and update the plan of care. 9. Document .Corrective action taken to resolve or minimize fall risk. 11. The fall team and DON reviews incidents weekly and make a final interdisciplinary note. R29 was admitted to the facility on [DATE]. Diagnoses included dementia with agitation, history of stroke, repeated falls, weakness, unsteadiness on feet, and difficulty walking. R29's Minimum Data Set (MDS)…
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.
- Potential for harm · D2024-11-13 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not have documentation included in resident's medical record that the residents and/or the resident's responsible party received education regarding the benefits and potential side effects of the influenza vaccine, and the resident (R), either received the influenza immunization or did not receive the influenza immunization for 3 out 5 (R3, R13, R15) residents sampled. R3, R13, and R15 did not have declinations on file, nor was there documentation stating these residents or their representatives refused the vaccine and were educated on the benefits of receiving the influenza vaccine. Findings include: The facility policy titled, Influenza and Pneumococcal Vaccines Applies To: Residents reviewed 3/2024, states in part, Purpose: ensure resident's vaccinations are given as current CDC guidelines recommend. The CDC Influenza Vaccine Timing for Adults reads, in part, One dose of influenza vaccine is recommended for adults each flu season . R3 was admitted 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.
- Potential for harm · D2023-09-07 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility did not ensure personal privacy for 2 of 4 residents (R2 and R28) during personal cares and medical treatment. R2 and R28's curtains were not shut during cares and medical treatment to ensure personal privacy. This is evidenced by: The facility policy, entitled Privacy/Dignity, dated 03/2023 states in part Resident's privacy and dignity is maintained at all times and by all staff during all cares and interactions. On 09/07/23 at 9:55 AM, Surveyor asked R2 if it was ok for Surveyor to watch staff transfer R2 into bed. R2 indicated privacy doesn't matter here. Surveyor observed Certified Nursing Assistants (CNA) M and N lower R2 into bed. CNAs removed R2 shoes, then pulled down R2's pants, and opened up incontinent product to change resident all while the curtain was open. The window in R2's room looked out towards a parking lot that anyone walking by could see in. Maintenance was mowing the lawn at the time outside the window and would be able to see in the window, if looking in the direction of the room. Surveyor asked R2 if it…
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.
- Potential for harm · D2023-09-07 · tag F0585 — failed to handle grievances — isolatedHonor 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
Based upon interview, record review and policy review, the facility did not ensure allegations of misappropriation were thoroughly investigated for 2 of 2 residents (R) (R22, R32) reviewed. R22 alleged she had lost clothing and did not know what had happened to the clothing. The facility did not complete a thorough investigation of the incident. R32's Power of Attorney (POA) said that R32 had lost a stuffed animal and was mentioned to staff but never knew what came of the complaint. The facility did not complete a thorough investigation of the incident. This is evidenced by: On 09/05/23 at 10:27 AM, Surveyor interviewed R22 regarding lost or stolen items. R22 said they had lost some clothing and had mentioned it to staff, and they were unsure how long the clothing had been missing. R22 was unsure what had happened and did not know if she had ever seen the clothing again. R22's most recent Brief Interview for Mental Status (BIMS) on 06/27/23 is a score of 15, meaning R22 is alert, oriented, and able to answer questions correctly. On 09/07/23 at 11:48 AM, Surveyor reviewed progress…
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.
- Potential for harm · D2023-09-07 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 complete and implement baseline or comprehensive care plans for 1 of 12 residents (R245) within 48 hours of admission, which included instructions on how to provide effective and person-centered care for the resident. No baseline care plan was developed within 48 hours to address the minimum healthcare information necessary to properly care for R245, including, but not limited to, such areas of catheter care, weight loss, functional abilities, and the assistance R245 requires. This is evidenced by: The facility policy, entitled Comprehensive Nursing Assessment, dated April 2019, states: 1. A RN [Registered Nurse] initiates nursing assessment focus on newly admitted residents that occurred during the shift and completes a temporary care plan that serves as the interim care plan. R245 was admitted to the facility on [DATE]. On 08/08/23, R245 was discharged to the hospital and admitted back to the facility on [DATE]. On 09/06/23 at 11:20 AM, Surveyor could…
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.
- Potential for harm · Dcited before2023-09-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure a comprehensive care plan was achieved for 2 of 12 residents (R) reviewed for care plans (R31, R245). R31 did not have a care plan to address incontinence care. R245 did not have a care plan to address falls, nutrition, pressure injuries, and catheter care. This is evidenced by: R31 was admitted to facility on 04/13/23. Quarterly Minimum Data Set (MDS), completed and dated 07/21/23, indicated R31 was occasionally incontinent. R31 was coded to require supervision for toileting and extensive assist personal hygiene. R31's Activities of Daily Living (ADL) care plan states . set up and wash own peri care. A care plan was not developed for urinary incontinence and assistance with personal hygiene. On 09/07/23 at 9:09 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D, who stated R31 wears pull ups and is usually incontinent of urine when arises in the am and at least 1x shift. On 09/07/23 at 9:47 AM, Surveyor interviewed CNA E…
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.
- Potential for harm · Dcited before2023-09-07 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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
Based on observation, record review and interview, the facility did not review and revise the comprehensive care plans for 1 of 12 sampled residents (R), R28. R28's care plan was not updated to identify the resident no longer has to be on contact precautions. This is evidenced by: On 09/05/23, Surveyor reviewed R28's care plan with a printed date of 09/07/23. It stated, Contact precautions due to MRSA + wound culture. May come out of room for meals and activities as long as wound is covered and drainage is contained. On 09/07/23 at 10:17 AM, Surveyor observed wound care being done on R28. Staff did not apply personal protective equipment (PPE) other than gloves. On 09/07/23, Surveyor interviewed Registered Nurse (RN) I and asked if R28 was on any precautions. RN I indicated R28 had history of Methicillin Resistant Staph Aureus (MRSA) but was no longer on precautions. Surveyor interviewed Director of Nursing (DON) B and asked if R28's care plan was still current. DON B indicated it was not. DON B indicated R28 was off of precautions on Aug. 24th and would look for the information.…
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.
- Potential for harm · Dcited before2023-09-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 the resident environment remained as free of accident hazards as possible for 2 of 5 residents (R) reviewed for room water temperature (R41, R10) and 1 of 4 residents (R245) reviewed for falls. Hot water temperatures in R41's and R10's rooms exceeded the recommended maximum temperature of 115 degrees Fahrenheit plus or minus two degrees. R245 did not have a fall assessment completed after a fall occurred. This is evidenced by Example 1 Surveyor reviewed the facility water temperatures logbook that documents the required hot water temperatures in resident rooms to be between 110 - 115 degrees Fahrenheit. On 09/06/23 at 9:55 AM, Surveyor used a thermometer to check the hot water temperature for R41's room. After 20 seconds, the hot water temperature reached 118.9 degrees Fahrenheit. On 09/06/23 at 10:05 AM, Surveyor used a thermometer to check the hot water temperature for R10's room. After 30 seconds, the hot water temperature…
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.
- Potential for harm · D2023-09-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure 1 resident (R) of 3 residents (R31) reviewed with a change of bladder continence status received services to restore continence status. The facility did not ensure a medical rationale to justify a catheter change on a scheduled basis for 1 of 2 residents (R9) reviewed. R31 was assessed on admission as being continent of bladder. On 07/21/23, R31 was assessed as occasionally incontinent and did not receive services to restore continence status. R9's indwelling catheter was ordered to be changed on a scheduled basis without a medical rationale. This is evidenced by: Facility policy entitled Bowel and Bladder Tracking, Assessment & Evaluation dated 5/2016, which states, Policy: Bowel and bladder tracking, assessment and evaluation will be started on admit and completed with initial care plan process, readmission, quarterly, and with significant change in condition or 7 days and after Foley Catheter removed: Procedure: .2. Once the bowel…
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.
- Potential for harm · D2023-09-07 · tag F0700 — isolatedTry 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 ensure prior to the installation or use of bed rails, the facility attempted to use alternatives, ensure the resident is assessed for the use of bed rails, which includes a review of risks including entrapment; and informed consent is obtained from the resident or if applicable, the resident representative for 3 of 3 residents (R) R14, R245, R16. The facility did not ensure the grab bars are appropriate for R14 and did not assess risk of entrapment versus benefit. The facility failed to assess R245 for risk of entrapment prior to installing bed rails. The facility did not assess R16 for risk of entrapment prior to installing bed rails. This is evidenced by: On 09/06/23 at 7:59 AM, Surveyor observed bilateral grab bars on R14's bed. R14 was admitted to facility on 10/27/23 and has diagnoses that include Parkinson's, dementia, and unsteady gait. R14's most recent quarterly Minimum Data Set (MDS), dated [DATE], indicated problem with both short…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2026-03-19 for 76 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to CARE & REHAB — 6 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.5 | -0.5 vs chain |
| Health inspection | 2 of 5 | 3.5 | -1.5 vs chain |
| Staffing | 5 of 5 | 4.0 | +1.0 vs chain |
| Quality measures | 2 of 5 | 2.5 | -0.5 vs chain |
The other 5 homes this chain runs (chain average 3.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| THAYER, GRANT | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | 100% | since 01/01/2017 |
| SENIOR MANAGEMENT INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| BECHTEL, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/10/2025 |
| CORTON, NICOLA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/05/2023 |
| LINGEN, THOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/28/2025 |
| SADOWSKA, TIMOTHY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/10/2025 |
| VOELTZ, KRISTIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2018 |
| CUMBERLAND CAMPUS LLC | Organization | ADP OF THE SNF | — | since 02/25/2025 |
CMS files one row per role, so the 18 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $160K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WI
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.
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 525712. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-18, 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.