Elroy Health Services

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

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.

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.

46.0% 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 70 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 50.0% 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 34 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 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% 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.

Staffing

How full it usually is: this home is certified for 80 beds and averages 64.2 residents a day — about 80% occupied, or roughly 16 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.28 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.90 hrs/resident/day on weekends vs 3.42 on weekdays — 15% thinner on weekends. RN hours go from 0.88 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% 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

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

Inspection deficiencies

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

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.

38 citations, most serious first. The 14 most serious are shown; the remaining 24 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-05-20 · 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 interview and record review, the facility did not ensure each resident receives adequate supervision and safety to prevent accidents and hazards for 1 of 1 Residents reviewed for smoking (R51).On 4/5/26, R51 was observed by staff to be smoking an illegal substance in his room. R51 had a history of illicit drug use, however, this was not addressed upon R51's admission. No monitoring was put in place for R51 regarding the use of illegal substances. R51 has a roommate, and residents in rooms near R51 use oxygen.The facility's failure to provide adequate supervision and protect residents from smoking in the facility and illegal substance use created a finding of immediate jeopardy (IJ) that began on 4/5/26. Surveyor notified NHA A (Nursing Home Administrator) and VPS E (Vice President of Success) of the immediate jeopardy on 5/7/26 at 1:50 PM. The immediate jeopardy was removed on 5/7/26. However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as…

  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
• Immediate jeopardy · Jcited before2025-03-03 · 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 each resident received care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services to promote healing and prevent new injuries from developing for 2 of 5 residents (R35 and R44) reviewed for pressure injuries. R35 was at risk for PI development. R35 developed two stage 3 facility acquired PIs that deteriorated. Observations were made of multiple layers between R35 and the air mattress. The facility failed to provide education and/or risks vs benefits when R35 declined repositioning. Staff did not ensure consistent documentation of repositioning or incontinence care, which were noted contributors to R35's PIs. Staff did not protect R35's periwound when applying the prescribed treatment. The facility's failures to implement preventive interventions for residents at risk for PIs, failure to provide education and/or risks vs.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-07-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 sampled residents (R2). R2 had a fall on 5/29/25. PA D (Physician Assistant) ordered x-rays STAT (right away) due to complaints of pain to right wrist and right hip. X-rays did not get completed as ordered. R2 was shaking due to severe pain the next morning and was sent to the hospital. R2 was diagnosed with a fracture to the right hip and pelvis as well as avulsion (a small piece of bone pulled off the wrist bone, causing a small fracture) to right wrist. The facility's failure to get the x-rays completed STAT as ordered resulted in a delay in treatment for R2. Evidenced by: The facility policy entitled Change in Condition, dated 9/20/22, states, in part: . A facility should immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident's representative when there is an…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-07-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure a resident's environment remained free of accidents and hazards for 1 of 3 residents (R3) reviewed for falls. R3's family provided information related to R3's familiar routine and preferences. The facility failed to get this information on R3's baseline care plan, on R3's comprehensive care plan, or get it to the front line staff to use for fall prevention. R3's alarm did not sound when she self transferred. R3 fell and sustained a hip fracture. The facility's management staff reported to Surveyor that R3 has behaviors of deactivating her alarm system. R3's medical record does not contain goals, monitoring, or interventions related to this behavior in regard to fall prevention. Facility staff used education with R3 as an intervention for fall prevention when R3 was only oriented to self, noted to be confused at baseline, was assessed to have severe cognitive impairment, and have a diagnosis of Alzheimer's. Evidenced by: Facility…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-20 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  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 immediately notify and consult with a resident's physician when there was a change in condition. This occurred for 2 of 5 Residents (R68 & R6) reviewed for notification of change in condition. On 10/26/25, R68 had a BP (Blood Pressure) of 68/52, was feeling dizzy and lightheaded. Throughout the night R68 had BPs readings of 80/40, 89/56, and 94/58. The next morning on 10/27/25 at 9:15 AM, R68 had a fall. The facility did not notify physician of change in condition throughout the night. On 3/5/26, the facility sent an e-Interact communication to the provider of R6's change of condition. The facility did not follow up with the provider regarding the change of condition to get any new orders or monitoring recommendations for R6 for several hours, after the change of condition was noted. This is evidenced by: The facility's policy, entitled Change in Condition of the Resident, dated 9/20/22, states, in part: . Policy: A facility should immediately inform the…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-20 · tag F0582 — isolated
  Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview the facility did not provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and the Notice of Medicare Non-Coverage (NOMNC); thus, did not provide the notice of Medicare services ending and the accurate potential financial liability to residents whose Medicare coverage was ending for 1 of 3 residents reviewed (R48).R48 was receiving Medicare A benefits. R48 was not provided with the NOMNC and SNFABN form thus not being provided with the accurate financial liability. Evidenced by:The facility's policy titled Advance Beneficiary Notice dated 5/12/25 states in part .5. To ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The notices must nit be provided while the resident/ representative is under duress or in an emergency situation.R48's Medicare coverage ended on 4/22/26. R48…

  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 before2026-05-20 · 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, interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 16 sampled Residents (R7).R7 reported that facility staff do not assist with shaving, despite R7 having their own shaver. R7 noted to have approximately 1/4 facial hair on their chin.Evidenced by:The facility's policy titled Activities of Daily Living (ADLS) dated 7/26/22 states in part .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.R7 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder (a mental health condition characterized by significant mood swings, including manic (or hypomanic) episodes and depressive episodes), dementia, polyneuropathy (nerve disease caused by damage to many nerves, often due…

  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 · D2026-05-20 · tag F0745 — failed to provide medically-related social services — isolated
  Provide medically-related social services to help each resident achieve the highest possible quality of life.
  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 provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 2 residents (R43) reviewed for transportation for medical appointments. R43 had a medical appointment scheduled for 5/4/26 and the facility failed to arrange transportation. Evidenced by: The facility does not have a transportation policy. R43 was admitted to the facility on [DATE] with diagnoses that include cognitive communication deficit (a condition where cognitive impairments disrupt a person's ability to communicate effectively, despite intact language or speech abilities), cirrhosis of liver (a complication of long-term inflammation of the liver. It results in the replacement of healthy liver tissue with scar tissue, called fibrosis), alcohol abuse, and hepatitis C (a liver disease caused by the hepatitis C virus).R43's most recent MDS (Minimum Data Set) dated 4/30/36 states that R43 has 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 · D2026-05-20 · 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 that it was free of medication error rates of 5% or greater. There were 2 errors out of 39 opportunities that affected 2 out of 5 residents (R54 & R46) included in the medication pass task, which resulted in an error rate of 5.13%.R54's orders include levothyroxine daily at 5:30 AM. Staff administered R54's levothyroxine at 8:09 AM. Staff administered R54's levothyroxine and calcium at the same. Staff administered R54's levothyroxine at the wrong time and against manufacturer's directions not to administer with Calcium.Staff administered R46's levothyroxine at 7:46 AM. The order is to administer levothyroxine at 6:00 AM. Staff administered this medication late.Evidenced by:The facility policy entitled Medication Administration, dated 1/26, states, in part: . POLICY: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-01 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent 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 interview and record review, the facility did not ensure that 1 of 3 residents (R3) reviewed for receiving a psychotropic medication were free from unnecessary drugs. R3 receives Olanzapine, an antipsychotic medication, for Alzheimer's disease with late onset. This is evidenced by: The facility policy titled, Use of Psychotropic Medications, reviewed 4/27/25, includes: it is the intent of this policy to ensure that residents only receive psychotropic medications when other non-pharmacological interventions are clinically contradicted. Additionally these medications should only be used to treat residents medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Adequate indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and after any other treatments have been deemed clinically contradicted. For psychotropic…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-03-03 · tag F0725 — failed to have enough nursing staff — widespread
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  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 sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (R). This has the potential to affect all 68 residents residing at the facility. Surveyors entered on the weekend due to the facility triggering for low weekend staffing. NHA A (Nursing Home Administrator) indicated the schedule is based on the census and hours per patient day (HPPD), which does not take into consideration the acuity of the facility's resident population. Residents in Resident Council voiced concerns that staff take too long to answer call lights and meal trays on the halls are not passed timely due to staff not being available. R56 voiced concerns about long wait times when wanting to get up. Staff stated there are care items they cannot complete for residents due to having low staffing. This is evidenced by: The Facility Assessment Tool, date 1/3/25, states in part:…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-03-03 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 68 residents who reside at the facility. Surveyor observed dietary aide without a beard restraint in the kitchen. Surveyor observed garbage cans near the food prep area without lids. Surveyor observed spilled food or drink in the walk-in fridge. Evidenced by: The facility policy, Employee Sanitary Practices- Food and Nutrition Services, dated, 7/27/22, states, in part; .All food and nutrition services employees will practice good personal hygiene and safe food handling procedures .1. Wear hair restraints (hairnet, beard restraint) to prevent hair from contacting exposed food . On 2/16/25 at 9:45 AM, Dietary Manager K (DM) and Surveyor toured the kitchen. Surveyor observed Dietary Aide L (DA) in the kitchen not wearing a beard restraint. Surveyor observed garbage cans near the food prep area without lids. Surveyor observed yellow substance spilled in the walk-in refrigerator. DM K…

  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 · Fcited before2025-03-03 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interview, and record review the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 68 residents (R) residing in the facility. The facility's outbreak that started in October 2024 was resolved too early. Facility staff were unaware of their current outbreak and were not following proper source control during the outbreak. Staff surveillance was not complete for staff illnesses and staff returned to work too early from illnesses. This is evidenced by: The facility's policy titled Infection Prevention and Control Program, dated 7/23/24, states in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-03 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  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 each resident had a safe, clean, comfortable, and homelike environment for 1 of 20 sampled residents (R316) and 6 of 12 supplemental residents ((R15, R11, R30, R18, R26, R42). R316, R42, R15, R11, R30, R18, and R26 indicated that the dining room was very cold, and they were wearing jackets or wrapped in blankets to stay warm. Resident Council meeting minutes dated 1/23/25, indicated the facility was aware that residents had concerns of it being too cold in the dining room. Evidenced by: Facility policy, entitled Safe and Homelike Environment Policy, dated 6/16/22, includes in part . Definitions: Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents . Policy Explanation and Compliance Guidelines . 7. The facility will maintain comfortable 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.

  Resident Rights 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.

Fines & penalties

$33,320 in federal fines across 1 penalty.

• $33,320 — penalty dated 2025-07-01

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 NORTH SHORE HEALTHCARE — 59 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 →

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

CMS files one row per role, so the 34 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

7 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 $353K 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