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Dove Healthcare - West Eau Claire

1405 Truax Blvd, Eau Claire, WI 54703 · For profit - Limited Liability company · 83 certified beds · (715) 552-1030 Medicare & Medicaid certified

Call the home — (715) 552-1030 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • about 17% of its spending goes to commonly-owned related companies

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

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1221 Whipple St · (715) 838-6020 · Call to confirm hours
Pharmacy
1400 Bellinger St · (715) 838-6000 · Call to confirm hours
Grocery
2615 North Clairemont
Park
3309 County Farm Rd · Typically dawn to dusk
Place of worship
3735 Jeffers Rd · (715) 514-3552

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 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 rating5★
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 increased15.3%16.1%15.4%typical
Long-stay residents who lose too much weight1.9%5.1%5.4%better
Long-stay residents with a catheter left in their bladder1.7%2.1%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.6%2.7%2.0%better
Long-stay residents with depressive symptoms4.1%5.7%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.2%3.3%3.3%typical
Long-stay residents whose ability to walk worsened16.4%18.4%16.1%typical
Long-stay residents on antianxiety or hypnotic medication15.8%16.9%18.9%better
Long-stay residents given the seasonal flu vaccine98.2%95.0%95.3%typical
Long-stay residents with pressure ulcers5.6%5.0%4.7%worse
Long-stay residents with worsening bladder/bowel control22.4%24.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table6.9%15.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.4%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine86.2%82.2%79.4%typical
Short-stay residents rehospitalized after admission22.4%23.1%22.6%typical
Short-stay residents with an outpatient ER visit12.0%15.5%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.931.661.67worse
Long-stay outpatient ER visits per 1,000 resident days1.812.291.80typical

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.

52.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 176 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.7%U.S. median 51.5%
Got home and stayed home
9.3%U.S. median 10.7%
Went back to hospital
67.7%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 67.7% 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 127 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 SNF52.7%CMS range 45.6–59.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.3%CMS range 7.0–11.210.7%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 discharge67.7%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 discharge60.6%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 discharge62.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.0%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 setting95.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or 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 hospitalization6.7%CMS range 3.9–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.891.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.97
RN hours/ resident / day
0.63
LPN hours/ resident / day
3.64
Aide hours/ resident / day
6.23
Total nurse hours/ resident / day
1.28
RN hoursweekends
41.0%
Total nursing turnover
41.9%
RN turnover

How full it usually is: this home is certified for 83 beds and averages 69.9 residents a day — about 84% 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 6.23 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.97 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.64 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 5.46 hrs/resident/day on weekends vs 6.54 on weekdays — 17% thinner on weekends. RN hours go from 2.24 to 1.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2026-06-10)
6
at the previous standard inspection (2025-03-20)

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.

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

  • Actual harm · Gcited before2024-02-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure a resident received adequate supervision and assistance to prevent falls and injury. This occurred for 1 of 5 residents (R) reviewed for falls, (R30). The facility did not report to oncoming staff, nor change R30's care plan to reflect the change in transfer status for R30. Staff utilized a walker to transfer R30, resulting in actual harm when R30 had a fall that resulted in a fractured femur and hip requiring surgery, and fractured rib. Thin liquids were observed in R17's room, who had a dietary order for honey-thickened liquids and not to leave R17 unattended with liquids. Findings include: Example 1: The facility policy, entitled Fall Risk Recognition and Fall Prevention Program, states: .When a fall occurs, electronic medical record documentation is completed. The documentation includes specific information related to the fall so that the investigation of the fall along with the evaluation of current and additional preventative…

    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 · E2026-06-10 · tag F0628 — pattern
    Provide 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 interview and record review, the facility did not notify the Ombudsman of resident transfer to the hospital for 4 of 5 residents (R76, R51, R30, and R1) reviewed.R76 was transferred to the hospital on [DATE]. The Ombudsman was not notified of this transfer.R51 was transferred to the hospital on [DATE]. The Ombudsman was not notified of this transfer.R30 was transferred to the hospital on [DATE], 04/11/26, 04/17/26, 5/15/26, 5/22/26, and 5/29/26. The Ombudsman was not notified of these transfers.R1 was transferred to the hospital on [DATE] and 05/30/26. The Ombudsman was not notified of these transfers. This is evidenced by: Facility policy titled, Transfer and Discharge, with a revised date of 11/2025, states: .10. Emergency Transfers to Acute Care. h. Transfer notices will be provided to the Ombudsman. They may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices. Example 1 R76 was admitted to the facility 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-10 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility did not ensure a resident (R) had the right to refuse a medication for 1 of 4 residents (R76).-R76 gave non-verbal indications regarding placement of a Scopolamine patch, and Medication Aide (MA) H continued to place the patch on R76.Findings include:On 06/09/26 at 8:50 AM, Surveyor observed Medication Aide (MA) H administering medications to R76. MA H did not explain to R76 what MA H was going to do before attempting to apply a Scopolamine patch behind R76's left ear. While trying to apply the patch, Surveyor observed R76 grimacing and pulling R76's head away. R76 was jerking R76's head from side to side. MA H asked R76 if it was ok for MA H to try again, and R76 shook their head, indicating no. MA H gently held R76's face with the left hand and placed the patch behind R76's left ear with the right hand. R76 was observed to pull away from MA H. MA H placed the patch behind R76's left ear.On 06/09/26 at 9:43 AM, Surveyor interviewed MA H regarding placement of the patch. MA stated R76 does not usually refuse the patch…

    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 · D2026-06-10 · 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

    Based on observation, interview, and record review, the facility did not ensure the timeliness of revisions for each resident's person-centered, comprehensive care plan for 1 of 18 residents (R) reviewed (R66).-R66 had tracheostomy removed on 11/12/25 and care plan currently includes interventions related to trach care.-R66 now takes food orally and is on a mashable texture. Care plan states all nutrition is administered via gastrostomy tube and is full liquid.Findings include:The facility policy titled, Comprehensive Care Plan, last revised on 03/10/25, includes: The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. The comprehensive care plan will describe.the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.On 06/08/26 at 10:07 AM, Surveyor interviewed R66 and Family Member (FM) W regarding care received by the facility. Surveyor observed R66 no longer had a tracheostomy. FM W stated R66…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that 1 of 4 residents (R) reviewed for pressure injuries (PI) (R1) received care consistently with professional standards of practice to prevent further deterioration and promote healing of an existing PI. R1 was at risk for PI development and had 2 existing PIs. The facility failed to provide adequate wound care treatment to R1's PI on coccyx.Findings include: Facility policy titled, Pressure Injury Prevention and Management, dated last revised 01/26, states: .4. Interventions for prevention and to promote healing; c. ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. R1 was re-admitted to the facility on [DATE], with diagnoses including unspecified dementia, asthma, chronic respiratory failure, severe sepsis with septic shock, infection reaction due to indwelling urethral catheter, type 2 diabetes mellitus, pressure ulcer of sacral region stage 3, and benign prostatic hyperplasia. A suprapubic…

    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 · D2026-06-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure residents with an indwelling foley catheter received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) for 2 of 4 residents (R) reviewed (R76 and R1) .R76 had an indwelling foley catheter which was not secured to prevent trauma or movement of catheter tubing.R1's foley catheter bag was leaking. Facility staff placed leaking catheter bag in bin placed on floor to collect the leaking urine. This is evidenced by: Facility policy titled, Catheter Care, with a revised date of 02/2026, states: Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.10. Ensure the catheter tubing is secured by use of stat lock or leg secure device.11. Report abnormal findings to the nurse and document any care that needs to be in the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-10 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 3 residents (R) reviewed (R76).Facility did not ensure R76's percutaneous gastrostomy (PEG) tube was properly placed prior to administering medications.This is evidenced by:Facility policy titled, Care and Treatment of Feeding Tubes (Enteral Tubes), with a revised date of 05/05/25, states: .6. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location: a. Tube placement will be verified before beginning a feeding and before administering medications.R76 was admitted to the facility on [DATE] with dysphagia following cerebral infarction. A PEG tube was in place on admission to administer enteral feeding and medication administration.On 06/09/26 at 8:54 AM, Surveyor observed Medication Aide (MA) H disconnect R76's tube feeding to administer medications. 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 · D2026-06-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure that 1 of 1 resident (R) reviewed received appropriate respiratory care during administration of respiratory therapy (R1). Registered Nurse (RN) P did not perform post respiratory assessments for R1 when administering nebulizer treatments.Findings include: The facility policy titled Specific Medication Administration Procedures for Oral Inhalation Administration, dated 05/18, in part: .L. Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer. M. Approximately five minutes after treatment begins (or sooner if clinical judgement indicates) obtain the resident's pulse. T. Obtain post-treatment pulse, respiratory rate, and lung sounds and document findings in the medical record if indicated by facilities policy and procedures. R1 was re-admitted to the facility on [DATE] diagnoses including unspecified dementia, asthma, chronic respiratory failure, severe sepsis with septic shock, infection…

    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 · D2026-06-10 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure medication error rates are not 5 percent or greater for 2 of 4 residents (R) observed (R76, R73).-Nursing staff did not measure Voltaren gel prior to administration for R73.-Nursing staff splashed and spilled medications prior to administration via gastrostomy tube for R76.-Nursing staff did not flush the correct amount of water between medications for R76.-Nursing staff administered sublingual medication via gastrostomy tube for R76.Findings include:The facility policy titled, Medication Administration, last revised 01/01/25 states: Ensure that the six rights of medication administration are followed including right dose and right route.Example 1On 06/09/26 at 7:26 AM, Surveyor observed Medication Aide (MA) H administer medications to R73. R73 has an order for Voltaren gel 1% apply to right shoulder topically one time a day for pain. Apply 4 grams. Surveyor observed MA H open the tube, place two dime-size amounts of gel onto MA H'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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-10 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 18 residents (R) reviewed (R66, R76).-Certified Nursing Assistant (CNA) N performed restorative tasks for R66 without wearing Personal Protective Equipment (PPE). R66 is on enhanced barrier precautions.-Medication Aide (MA) H did not change gloves and perform appropriate hand hygiene prior to and during medication administration involving R76's feeding tube.Findings include:The facility policy titled, Enhanced Barrier Precautions, last revised January 2025, includes: Personal Protective Equipment (PPE) is necessary when performing high-contact care activities.Example 1On 06/08/26, Surveyor reviewed R66's medical record related to precautions. R66 was noted to be on Enhanced Barrier Precautions (EBP) related to indwelling Foley catheter.On 06/08/26 at 10:12 AM, Surveyor observed CNA N enter R66's room to perform restorative care. CNA N did not don any Personal…

    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 · F2025-03-20 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 63 residents residing in the facility. Findings include: On 3/20/25 at 11:40 AM, Surveyor interviewed Nutritional Services Director (NSD) S, requesting verification of her qualifications. NSD S reported she completed an all day certification course. The certificate NSD S provided is from the National Registry Of Food Safety Professionals and it states NSD S has successfully satisfied the requirements for the International Food Safety Manager under both Conference for Food Protection Standards and ISO/IEC 17024 Standards. Certificate issued 11/16/21 and expiration date is 11/16/26. Surveyor asked NSD S if she had other schooling or training other than the conference certificate, NSD S reported she did not. NSD S did state the facility does have a Registered Dietician that comes to the facility a couple of times a week and is available…

    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
Show the remaining 10 citations
  • Potential for harm · Fcited before2025-03-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview the facility did not prepare foods in a sanitary manner. Nutritional Service Aide (NSA) P did not allow the thermometer probe to air dry of alcohol prior to inserting into each of the nine food items intended to be served to residents for lunch. This had the potential to affect all 66 residents in the facilty. NSA N did not perform hand hygiene in between passing water pitchers to residents (R). This affected 10 of 10 residents observed receiving water pitchers (R48, R21, R20, R27, R22, R32, R45, R34, R60, and R269). NSA P prepared and served food to residents without proper hand hygiene and touched ready to eat foods with contaminated gloved hands. This affected 7 of 7 residents observed (R26, R267, R48, R22, R11, R6, and R268). This is evidenced by: Example 1 The facility procedure titled, Nutritional Services Procedure Appearance and Temperatures reviewed on March 2023 stated in part, 7. Temperatures will be taken by cleaning the thermometer with approved cleaning wipe, allowing cleaner to dry for 10-15 seconds, and placing the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that 1 of 3 residents (R) reviewed for pressure injuries (PI) received care consistent with professional standards of practice to prevent at risk of skin breakdown from occurring (R267). R267 was at risk for PI development. The facility failed to provide adequate and consistent repositioning as care planned. Findings include: Surveyor reviewed policy titled, Turning and repositioning, dated September 2024, last reviewed in October 2024, states in part: . #1. All residents at risk of, or with existing pressure injuries, will be turned and repositioned. #3. A routine schedule includes using both side-lying and back positions, alternating from the right, back, and left side. A resident's condition will determine whether a specialized turn schedule is warranted. #6. Repositioning techniques in bed: h. Ensure that heels are floated off the surface of the bed with pillows or devices designed to do so. If using heel protector, the heel must…

    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 before2025-03-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not provide the needed supervision and care planned approaches to prevent a fall. The facility practice had the potential to affect 1 of 5 residents (R61) reviewed for falls. Certified Nursing Assistant (CNA) C did not remain at bedside after removing R61's bedside mat and body pillow placing R61 at risk for fall and injury. This is evidenced by: Surveyor requested and received the facility policy titled Fall Prevention Program dated 8/2024. The policy in part read: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. ~Each resident's risk factors and environmental hazards will be evaluated when developing the residents comprehensive plan of care. Surveyor reviewed R61's most recent minimum data set (MDS) which was an admission MDS dated [DATE]. The MDS indicated R61 usually understands, usually is understood with 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and policy review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, did not ensure only authorized personnel had access to medications for 3 of 3 random observations. -One observation was made of resident (R) medications left on top of the medication cart when the cart was unattended and out of view of staff. (R37) -Observation of prescribed Nystatin powder left unattended in R14's room during 2 observations Findings include: Surveyor reviewed policy titled, Preparation and General Guidelines, dated May 2018, states in part: . A. The following equipment and supplies are acquired and maintained by the facility for the proper storage, preparation, and administration of medications: 1. Lockable medication carts, cabinets, drawers, and/or rooms with well-lit medication preparation areas . Example 1 On 03/18/25 at 4:21 PM, Surveyor observed an unlocked medication cart down 2300 hall. Surveyor observed no staff members in sight. Surveyor observed the unsupervised 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 · Dcited before2025-03-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Example 3 On 3/19/25 at 6:42 AM, Surveyor observed R61's room door with a posting that read Enhanced Barrier Precautions. Surveyor observed CNA C don gloves and a gown to enter R61's room to prepare R61 for a shower. CNA C explained R61 is on Enhanced Barrier Precautions due to having a feeding tube. CNA C did not perform hand hygiene prior to donning the gown and gloves to care for R61. CNA C rolled R61 side to side in bed to remove bedding from under R61. CNA C expressed the bedding was wet. CNA C bagged the wet linens, removed her gloves and donned gloves to proceed with R1's preparation for his shower. CNA C did not perform hand hygiene when removing her soiled gloves before donning clean gloves. On 3/19/25 at 10:20 AM, Surveyor spoke with CNA C about the observation. CNA C expressed she should have done hand hygiene before donning PPE and with change of gloves. CNA C further expressed it is important to keep everything clean and to prevent cross contamination from dirty to clean. On 3/19/25 at 2:40 PM, Surveyor spoke with Registered Nurse (ICP/RN) D, who is the facility's…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-07 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety by not wearing beard nets appropriately. This has the potential to affect 31 of the 64 residents residing in the facility (R34, R37, R8, R5, R1, R10, R20, R49, R29, R24, R25, R21, R23, R162, R38, R42, R40, R3, R48, R31, R28, R45, R43, R12, R19, R27, R16, R213, R35, R9, and R7). Findings include: The federal food code, entitled FDA Food Code 2022, dated as the January 18, 2023, Version, 2-402 Hair Restraints. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. On 02/05/24 at 11:39 AM, Surveyor observed Dietary Aide (DA) CC plating food off the steam table for the residents on the facility's second…

    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 · Ecited before2024-02-07 · 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, interview and record review, the facility did not maintain an infection prevention and control program for proper linen handling, urine disposal, hand hygiene, and sanitizing mechanical lifts to help prevent the development and transmission of communicable diseases and infections for 10 of 64 Residents (R). (R13, R317, R313, R315, R17, R23, R39, R5, R42, and R30) Findings: The facility policy entitled, Linen Handling Guidelines last reviewed January 2023, stated in part: .4. Soiled linens are place in a garbage bag . 11. Bagged linens and garbage are kept away from body and floor when transporting to soiled linen room/container . Resident (R)13 has a diagnosis of Methicillin Resistant Staphylococcus Aureus (MRSA) via nasal swab and previously reported in the urine on 07/24/23. On 02/06/24 at 10:00 AM, Surveyor observed Certified Nursing Assistant (CNA) S pick up soiled towel and washcloth from R13's bed with bare hands, holding the linens against CNA S's body and carry the linen out of…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-07 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not ensure each resident is treated with dignity and receive assistance when requested in a manner and in an environment that promotes enhancement of his or her quality of life. This occurred for 1 of 16 residents (R) reviewed. (R17) Findings include: R17 was admitted to the facility on [DATE], with diagnoses including in part, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dysphagia, gastrostomy, and acute respiratory failure. R17's most recent Minimum Data Set (MDS) assessment, dated 12/11/23, indicated R17's Brief Interview for Mental Status (BIMS) scored a 13. A score of 13 indicates that the resident is cognitively intact. The MDS assessment identified that R17 required total extensive assistance for activities of daily living (ADL). R17's care plan indicates on 12/01/23 that R17 is non-ambulatory, assist of two staff with use of full mechanical lifts (Hoyer), and two staff assist in bed on both sides. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-07 · 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, interviews and record review, 2 of the 8 dependent residents (R) reviewed did not receive required assistance with Activities of Daily Living (ADL) of incontinence cares and eating of a meal. (R17 and R30) Findings include: Example 1 R17 was admitted to the facility on [DATE], with diagnoses including in part, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dysphagia, gastrostomy, and acute respiratory failure. R17's most recent Minimum Data Set (MDS) assessment, dated 12/11/23, indicated R17's Brief Interview for Mental Status (BIMS) scored a 13. A score of 13 indicates that the resident is cognitively intact. The MDS assessment identified that R17 required total extensive assistance for activities of daily living (ADL) and at risk for development of pressure injuries. R17's care plan indicates on 12/01/23 that R17 is non-ambulatory, assist of two staff with using a full mechanical lift (Hoyer) for transfers, and two staff assist for bed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that residents with a history of pressure injuries (PI) and severe peripheral vascular disease received necessary treatment and services, consistent with professional standards of practice for 1 of 1 resident (R) reviewed with pressure injuries. (R316) R316 was admitted to the facility with a PI to the right lateral ankle and a deep tissue injury (DTI) of the right heel. The facility did not ensure R316's feet were protected, heels observed not being floated, and inconsistent assessments of the wounds were noted. Findings include: Surveyor requested and reviewed the facility policy titled Skin Assessment and Pressure Ulcer Prevention dated last review January 2024. The policy in part reads: Procedure: 2. Licensed Nurse assessment is completed on admission, quarterly, annually, and with any change in condition. 3. During a skin observation the nurse will examine the resident and determine whether any of the following are present: c.…

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

    Quality of Life and Care 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 DOVE HEALTHCARE — 11 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 4 of 53.2+0.8 vs chain
Health inspection 3 of 53.1-0.1 vs chain
Staffing 5 of 53.6+1.4 vs chain
Quality measures 4 of 53.4+0.6 vs chain
The other 10 homes this chain runs (chain average 3.2★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
DOVE 8 OPCO HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2024
DIVINE HC HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2024
GOLDSTAR CAPITAL PARTNERS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2024
GOLDSTAR WISCONSIN ASSOCIATES, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2024
GOLDSTAR-DIVINE HOLDINGS DOVE 8 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2024
MARKOVITS, ISAAKIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 01/01/2024
RICHLAND, ILANIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2024
SEVERSON-SOLBERG, KRISTINIndividualCONTRACTED MANAGING EMPLOYEEsince 01/01/2024
SMETANA, ASHLEYIndividualW-2 MANAGING EMPLOYEEsince 01/01/2024
GOLDNER, DAVIDIndividualCORPORATE OFFICERsince 01/01/2024
KILEY, JEREMYIndividualCORPORATE OFFICERsince 01/01/2024

CMS files one row per role, so the 12 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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.

$9.2M
Net patient revenuemost recent cost report
-0.6%
Operating marginrevenue minus expenses
$1.6M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 52%Medicare 21%Other / private 27%

This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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

$432per resident / day
operating cost
$13,138per month
≈ monthly operating cost
$430per 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 525387. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-10, 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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