Avina of Fond du Lac
115 E Arndt St, Fond du Lac, WI 54935 · For profit - Individual · 50 certified beds · (920) 923-7040 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $7,446 in federal fines (most recent 2023-10-19)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.8% | 16.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.8% | 5.1% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.6% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.3% | 2.7% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 25.7% | 5.7% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.6% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.1% | 18.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 27.3% | 16.9% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.1% | 5.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 29.0% | 24.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.1% | 15.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.6% | 82.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.3% | 23.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 22.2% | 15.5% | 12.0% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
38.3% 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 33 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 34.6% 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 26 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 38.3%CMS range 24.2–51.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.4–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 34.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 26.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 19.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 50 beds and averages 44.4 residents a day — about 89% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.16 hrs/resident/day on weekends vs 3.95 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.47 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · J2023-10-19 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
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 resident and staff interviews and record review, the facility did not ensure a safe discharge for 1 of 3 residents R1 (Resident) reviewed for discharge. Prior to admission R1 lived in a motorhome in a campground, which is not wheelchair or walker accessible and has a [NAME] bed. On 10/13/23, R1 was taken, by transport van, to his motorhome, with 2 staff accompanying. R1 was unable to navigate the three steps into the motorhome with staff assistance. R1 started to fall backwards, and staff assisted R1 into his wheelchair. Staff observations of the interior of R1's motorhome were it was uninhabitable, with multiple jugs of urine, no bathroom facilities, no running water, no food, and full of junk. Staff contacted NHA A (Nursing Home Administrator) to make her aware of their observations. NHA A informed staff to have the transport van take R1 to the emergency room at the local hospital and leave him as he was no longer a resident of the facility. R1 was taken to the hospital and left by the transport…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-22 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
Based on observation and staff, resident, and family interview, the facility did not ensure a clean, comfortable, home-like environment for residents on the 100 wing. This practice had the potential to affect more than 4 of the 44 residents residing in the facility.A black and/or green, damp, and smudgeable substance was observed on walls and ceiling tiles on the 100 wing. In addition, a brown fuzzy growth was observed on a ceiling tile directly above the entrance to the common area/living room on the 100 wing. Findings include:The Centers for Disease Control and Prevention (CDC) website section titled Mold, dated 5/29/24, indicates: Stachybotrys chartarum is a greenish-black mold. It can grow on material with a high cellulose content, such as fiberboard, gypsum board, and paper. Growth occurs when there is moisture from water damage, water leaks, condensation, water infiltration, or flooding. Constant moisture is required for its growth .At present, no test exists that proves an association between Stachybotrys chartarum and particular health symptoms. Individuals with persistent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-22 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of drugs and biologicals for 1 resident (R) (R1) of 5 sampled residents.On 3/13/26, Licensed Practical Nurse (LPN)-I did not administer R1's dose of Estradiol as ordered.Findings include:The Facility's Medication Administration policy, revised January 2026, indicates: .1. Keep the medication cart clean, organized, and stocked with adequate supplies .23. Administer medication(s) according to physician order. 24. Correct any discrepancies and report to nurse manager.On 4/21/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including conversion disorder with motor symptom deficit, polycystic ovarian syndrome, asymptomatic premature menopause, and dysmenorrhea. R1's Minimum Data Set (MDS) assessment, dated 2/20/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had intact…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-11 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, the facility did not ensure a care plan was updated in a timely manner for 1 resident (R) (R2) of 4 sampled residents.R2's care plan was not updated in a timely manner after a resident-to-resident altercation.Findings include:The facility's Care Plan Revisions Upon Status Change policy, dated 1/6/25, indicates: .The comprehensive care plan will be reviewed and revised as necessary when a resident experiences a status change. On 2/11/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including dementia, urinary tract infection, and altered mental status. R2's Minimum Data Set (MDS) assessment, dated 1/16/26, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R2 had severe cognitive impairment. R2 had an activated Power of Attorney for Healthcare (POAHC).On 1/20/26, R2 had a physical and verbal altercation with another resident. The facility submitted a facility-reported…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-05 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the right to make healthcare decisions was provided for 1 resident (R) (R1) of 1 sampled resident. R1's Power of Attorney for Healthcare (POAHC) was not activated; however, R1's medical record contained multiple documents signed by POAHC-F. The facility did not have documentation that R1 consented to POAHC-F signing documents on R1's behalf.Findings include:On 1/5/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including encounter for palliative care, severe protein calorie malnutrition, malignant neoplasm of bladder, and type 2 diabetes. R1's Minimum Data Set (MDS) assessment, dated 9/14/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R1 had severely impaired cognition. R1 passed away at the facility on 9/21/25. R1's medical record contained a Power of Attorney for Healthcare document that designated POAHC-F as R1's number 2 agent. R1 was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, staff and resident interview, and record review, the facility did not ensure a clean, comfortable, or homelike environment for 1 resident (R) (R6) of 10 sampled residents. R6 reported to staff that the faucet in R6's bathroom did not work properly. The faucet was not repaired in a timely manner.Findings include:The facility's Reporting Maintenance Issues policy, revised 10/2025, indicates: All maintenance issues that may impact resident safety, clinical care, infection prevention, dignity, or facility operations must be reported immediately using the approved reporting process. Timely reporting is essential to minimize risk and ensure compliance with nursing home regulations and quality standards .7. Documentation: All maintenance issues must be documented, including: Date and time reported; Person reporting the issue; Description and location; Risk level and priority; Actions taken; and Completion date. Records must be retained in line with nursing home policy and regulatory…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-05 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of drugs and biologicals for 2 residents (R) (R1 and R7) of 8 sampled residents.On 9/11/25, Medication Technician (MT)-G administered another resident's medications to R1 and R7. Findings include:The facility's Medication Administration policy, revised 3/2025, indicates: .3. Identify resident by photo in the Medication Administration Record (MAR) .10. Ensure that the six rights of medication administration are followed: a. Right resident; b. Right drug; c. Right dosage; d. Right route; e. Right time; f. Right documentation .11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication, form, dose, route, and time.1. On 1/5/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of bladder, unspecified,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-07-17 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility did not ensure a Registered Nurse (RN) was on duty at least 8 consecutive hours per day 7 days per week. This practice had the potential to affect all 43 residents residing in the facility.The facility did not have an RN on duty 8 consecutive hours per day 7 days per week on 1/4/25, 1/5/25, and 2/16/25. From 7/15/25 through 7/17/25, Surveyor reviewed the nurse staffing schedules for sampled days based on the facility's Payroll Based Journal (PBJ). The facility triggered for low weekend staffing for Fiscal Year (FY) Quarter 2 (January 2025 through March 2025). The facility did not trigger for No RN Hours.The facility provided schedules for the following requested dates: 1/3/25, 1/4/25, 1/5/25, 1/6/25, 2/14/25, 2/15/25, 2/16/25, 2/17/25, 3/21/25, 3/22/25, 3/23/25, and 3/24/25.Surveyor cross-referenced the posted nurse staffing schedules with employee punches and noted there was not an RN scheduled on 3 (1/4/25, 1/5/25, and 2/16/25) of the 12 days reviewed.On 7/17/25 at 1:46 PM, Surveyor interviewed Director of Nursing (DON)-B…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-17 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure the safe and accurate administration of medication for 4 residents (R) (R3, R18, R28, and R7) of 23 sampled residents.Medication was observed on R3's overbed table. R3 did not have an assessment or a physician's order that indicated R3 could self-administer medication or store medication at the bedside.Medications were observed in a bin in R18's room and on R18's bedside table. R18 did not have an assessment or a physician's order that indicated R18 could self-administer medication or store medication at the bedside. In addition, R18 did not have an order for one of the medications.Medication was observed on R28's overbed table. R28 did not have an assessment or a physician's order that indicated R28 could self-administer medication or store medication at the bedside. In addition, R28 did not have an order for one of the medications.Medication was observed on R7's bedside table. Self-administration of medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-17 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each 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 observation, staff interview, and record review, the facility did not ensure a call light was within reach for 1 resident (R) (R16) of 23 sampled residents.During multiple observations, R16's call light was not within reach. In addition, R16's ability to use the call light was not assessed. Findings include: The facility's Call Light Policy, dated 10/2024, indicates: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response .1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light .3. Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system. 4. Special…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-17 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility did not implement policies and procedures to prevent abuse for 3 ((Certified Nursing Assistant)-C, CNA-D, and Laundry Aide (LA)-E) of 8 employees reviewed for caregiver background checks.The facility did not ensure Background Information Disclosure (BID) forms were signed and dated for CNA-C, CNA-D, and LA-E.Findings include:The facility's Abuse Prevention Program policy, dated 3/6/25, indicates the purpose of the policy is to assure the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment of residents. The policy indicates this will be done by .conducting pre-employment screening of employees.From 7/15/25 through 7/17/25, Surveyor reviewed caregiver background check information for 8 facility employees and noted the following:~ CNA-C was hired on 4/9/20. CNA-C's BID form was not signed or dated.~ CNA-D was hired on 5/30/25. CNA-D's BID form was not signed or dated.~ LA-E was hired 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.
Show the remaining 18 citations
- Potential for harm · D2025-07-17 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure range of motion (ROM) exercises were completed in accordance with a range of motion program for 1 resident (R) (R6) of 1 sampled resident.An occupational therapy (OT) discharge note indicated R6 was provided ROM exercises to decrease contractures and maintain ROM. R6's plan of care did not include the ROM exercises and staff did not provide ROM for R6. Findings include:From 7/15/25 to 7/17/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including cerebral vascular accident (CVA) (otherwise known as stroke) with aphasia, hemiplegia and hemiparesis affecting the right dominant side, and pressure ulcer of the sacral region. R6's Minimum Data Set (MDS) assessment, dated 4/21/24, had a Brief Interview for Mental Status (BIMS) assessment that was completed by staff due to R6's impaired cognition. R6 had a Guardian for decision making.A care plan, revised 7/15/24, indicated R6 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure an evaluation of smoking risks was completed for 1 resident (R) (R29) of 2 sampled residents.A Comprehensive Smoking Evaluation, dated 10/21/24, indicated R29 required supervision while smoking. On 7/10/25, staff completed a Smoking Quarterly Review that indicated R29 did not require supervision while smoking. Staff did not complete a comprehensive evaluation that supported the change from supervised to unsupervised smoking. Findings include:The facility's Resident Smoking Policy, dated 3/2025, indicates it is the policy of the facility to provide a safe and healthy environment for residents, visitors, and non-smoking residents .6. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if the resident is safe to smoke at all. A. Residents must be able to take themselves outside and back inside the facility. B. Residents must be able to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R35) of 23 sampled residents received the necessary care and services to prevent or monitor weight loss.R35 had a significant weight loss. Appropriate follow-up was not completed, including timely notification of the physician, Registered Dietitian (RD), and R35's Power of Attorney for Healthcare (POAHC). Findings include: The facility's Weight Monitoring policy, revised 7/11/25, indicates: A comprehensive nutritional assessment will be completed upon admission to identify those at risk for unplanned weight loss, gain, or compromise nutritional status. Assessments should include the following information: .c. Weight (do not use the hospital weight) .3. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following .: 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.
- Potential for harm · D2025-07-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 observation, staff interview, and record review, the facility did not ensure the necessary respiratory care and services were provided for 3 residents (R) (R2, R26, and R3) of 3 sampled residents.R2 used a nebulizer (a machine that transforms liquid medication into a fine mist that can be inhaled directly into the lungs) but did not have an order to clean the nebulizer after use. In addition, R2's care plan did not address how to clean or care for the nebulizer. R2 also used a continuous positive airway pressure (CPAP) machine but did not have orders for settings or maintenance of the machine.R26 used a nebulizer but did not have an order or care plan that addressed how to properly clean or care for the nebulizer after use.R3 had an order for as needed (PRN) oxygen that did not specify a flow rate. In addition, R3's plan of care did not indicate R3 used oxygen. Findings include: The facility's Noninvasive Ventilation policy, revised 12/3/24, indicates: It is the policy of this facility to provide…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-17 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure ongoing communication with a dialysis facility for 1 resident (R) (R2) of 1 resident who received dialysis services.R2 received dialysis three times per week. The facility did not ensure ongoing communication between the nursing facility and the dialysis facility prior to and following R2's dialysis appointments. In addition, R2's medical record did not specify which days of the week R2 went to dialysis.Findings include:The facility's Hemodialysis policy, revised 12/2/24, indicates: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis .The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards 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.
- Potential for harm · Ecited before2025-03-14 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and record review, the facility did not ensure dishes were washed and food was prepared in a safe and sanitary manner. This practice had the potential to affect all 46 residents residing in the facility. Staff did not appropriately test the sanitizing solution in the dishwashing sink. Cook (CK)-C did not wear gloves or wash hands appropriately when preparing pureed fish. Findings include: The facility's undated Cleaning Dishes-Manual Dishwashing policy, indicates: Dishes and cookware will be cleaned and sanitized after each meal .Check sanitation sink frequently using a test strip to assure the level of sanitizing solution is appropriate. Follow chemical manufacturer's guidelines to prepare sanitizing solution .Measure the appropriate amount of sanitizing chemical into the appropriate amount of water following the manufacturer's guidelines. Water should be 75 to 100° Fahrenheit (F). Test the sanitizing solution in the sink using the manufacturer's suggested test strips to assure appropriate level . On 3/14/25, Surveyor reviewed the posted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-14 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R10 and R11) were allowed continued use of assistive devices to enhance their quality of life. When R10 and R11 were admitted to the facility, R10 and R11 were allowed to use an electric wheelchair/ motorized scooter inside the facility. R10 and R11 were no longer allowed to to use the devices inside the facility after the facility changed their policy. Findings include: The facility's Motorized Mobility Aids: Wheelchairs, Carts, and Scooters policy, dated 10/29/24, indicates: .Motorized mobility aids are permitted in any outside area of the facility unless they pose a direct threat to the safety of others .Motorized mobility aids are operated in such a manner that they do not impede or interfere with normal resident flow, including a roommate's ability to freely access the common area of the room. When common area activities are in progress and crowded, the facility may request that those using…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-06-05 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility did not ensure a Registered Nurse (RN) was on duty at least 8 consecutive hours per day 7 days per week. This practice had the potential to affect all 46 residents residing in the facility. The facility did not have an RN on duty for 8 consecutive hours per day 7 days per week on 24 of 26 days reviewed. Findings include: Between 6/3/24 and 6/5/24, Surveyor reviewed the nurse staffing schedules for sampled days based on the facility's Payroll Based Journal (PBJ). The facility triggered for no RN hours on 25 weekend days between October 2023 and December 2023. On 6/3/24 at 11:42 AM, Surveyor interviewed Power of Attorney for Healthcare (POAHC)-H who indicated on Memorial Day (5/27/24), POAHC-H visited the facility and could not find a nurse. On 6/4/24, the facility provided schedules for the following requested dates: 10/1/23, 10/14/23, 10/15/23, 10/21/23, 10/22/23, 10/28/23, 10/29/23, 11/4/23, 11/5/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23, 12/2/23, 12/3/23, 12/9/23, 12/10/23, 12/16/23, 12/17/23, 12/23/23,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-06-05 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 46 of 46 residents residing in the facility. The facility did not ensure time/temperature control foods were labeled with open or use-by dates. Findings include: On 6/3/24 at 8:39 AM, Dietary Manager (DM)-C stated the facility follows the Wisconsin Food Code as their standard of practice. Open/Unlabeled/Undated/Expired Food: The Wisconsin Food Code 2020 documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety (TCS) Food, Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in (E), (F), and (H) of this section, refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-05 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R8) of 1 resident reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. R8 was transferred to the hospital on 3/4/24 and 4/28/24. R8 was not provided with a written transfer notice for either transfer. Findings include: The facility's Notice of Transfer and Discharge policy, with a revision date of 8/10/22, indicates: Prior to discharge or transfer, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing .Written notice of transfer or discharge will contain the following: The reason for transfer or discharge; the effective date of transfer or discharge; the specific location .A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure neurological checks were completed per policy for 2 residents (R) (R35 and R38) of 4 residents reviewed for falls. Staff did not consistently complete neurological checks after R35 fell on 2/3/24, 2/21/24, 4/13/24, and 4/21/24. Staff did not consistently complete neurological checks after R38 fell on 3/28/24. Findings include: The facility's Fall Prevention Program, effective date 5/17/22, contained the following information: Procedure: .7) Residents will be evaluated after a fall has occurred in an attempt to identify any causative factors that need correction. 8) At the time of the fall, the resident will be evaluated for any injuries . The facility's Neurological Assessment policy, revised on 9/25/23, contained the following information: Residents will have a neurological assessment completed when they experience a head injury or a change in condition that deems it necessary .Neurological assessments will be completed .when indicated for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-01 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 residents (R) (R3 and R2) of 3 sampled residents. In addition, the facility did not report an allegation of neglect to the State Agency (SA) for 1 (R1) of 3 sampled residents. The facility did not report an allegation of sexual abuse involving R3 and R2 to the SA, local law enforcement, R3's Power of Attorney for Healthcare (POAHC), or R2's court-appointed guardian. The facility did not report an allegation of neglect involving R1 to the SA. Findings include: The facility's Abuse Prevention Policy indicates: The purpose of the policy is to assure the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents .This will be done by: .filing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-01 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure allegations of abuse and neglect were thoroughly investigated for 3 residents (R) (R3, R2, and R1) of 3 sampled residents. The facility did not thoroughly investigate an allegation of sexual abuse involving R3 and R2. The facility did not thoroughly investigate an allegation of neglect involving R1. Findings include: The facility's Abuse Prevention Policy indicates: The purpose of this policy is to assure that the facility is doing all that is within it's control to prevent occurrences of abuse, neglect .This will be done by: .Identifying occurrences and patterns of potential mistreatment .Immediately protecting residents involved in identified reports of possible abuse, neglect .and making the necessary changes to prevent future occurrences .Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect .Upon…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure an assessment was completed by a Registered Nurse (RN) when a change in condition occurred for 1 Resident (R) (R2) of 3 residents reviewed. R2 had a change in condition that included slurred speech, increased confusion, and a left eye that wouldn't open. R2 was not assessed by an RN. R2 was sent to the hospital approximately two hours later and underwent brain surgery for a stroke. Findings include: On 11/2/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses that included acute kidney failure, recurring complicated urinary tract infections, acute respiratory failure, diabetes mellitus, and overactive bladder. R2's Minimum Data Set assessment, dated 9/1/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R2 had intact cognition. R2 required up to extensive assistance with activities of daily living (ADLs). On 11/2/23 at 9:30 AM, Surveyor interviewed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-19 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and resident and staff interviews, the facility did not ensure all allegations of abuse were reported timely to the State for 2 Residents (R4 and R9) of 11 sampled residents. R4 had an altercation with a staff member around other residents. The facility did not report the incident to the State. R9 complained that a staff member was rude, constantly yelling, and laughs at him. The facility did not report the incident to the State. Findings include: The facility's policy titled Abuse Policy, undated, contains the following information, in part . Policy: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. IV. Internal Reporting Requirements…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-19 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility did not ensure that all alleged violations involving abuse were fully investigated and the resident was protected during the investigation in accordance with State law through established procedures in 2 of 3 alleged abuse investigations out of a total sample of 11 residents reviewed (R4 and R9). R4 had an altercation with a staff member around other residents. The facility did not investigate the concern. R9 complained that a staff member was rude, constantly yelling, and laughs at him. The facility did not fully investigate the concern. Findings include: The facility's policy, titled Abuse Policy, undated, contains the following information, in part . Policy: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The purpose of this…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-17 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure the accurate administration of medication for 1 Resident (R) (R10) of 5 residents. R10 did not receive pain and anxiety medications timely because the facility did not have the medications available. Findings include: R10 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, anxiety disorder, Rheumatoid Arthritis, pain in right knee, radiculopathy (commonly referred to as a pinched nerve) lumbar region, pain in left leg, pain in thoracic spine, low back pain, bilateral osteoarthritis of the knee, chronic pain, and opioid dependence. R10's Minimum Data Set (MDS) assessment, dated 3/1/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R10 did not have impaired cognition. On 5/15/23 at 11:54 AM, Surveyor interviewed R10 who stated the facility keeps running out of R10's lorazepam (anti-anxiety medication) and Percocet (narcotic pain medication) that R10 can…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-17 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff and resident interview, and record review, the facility did not maintain an infection control program designed to help prevent the development and transmission of disease and infection for 1 Resident (R) (R8) of 6 residents observed for infection control practices. Certified Nursing Assistant (CNA)-D did not appropriately change gloves and cleanse hands during the provision of cares for R8. Findings include: The facility's Hand Hygiene policy, revised 5/23, contains the following information: Hand Hygiene means cleaning hands by using handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel). On 5/15/23 at 9:04 AM, Surveyor observed CNA-D provide perineal and catheter care for R8. CNA-D applied lotion to R8's legs with gloved hands and then grabbed clean wash cloths from a staff who entered the room. CNA-D put socks on R8 and pulled shorts up to R8's calves. With the same gloved hands, CNA-D handed a wash cloth to R8 to wash R8's face and assisted R8 with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$7,446 in federal fines across 1 penalty.
- $7,446 — penalty dated 2023-10-19
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 AVINA HEALTHCARE — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.2 | -0.2 vs chain |
| Health inspection | 2 of 5 | 2.1 | -0.1 vs chain |
| Staffing | 2 of 5 | 1.9 | +0.1 vs chain |
| Quality measures | 2 of 5 | 3.3 | -1.3 vs chain |
The other 8 homes this chain runs (chain average 2.2★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| REBEL, IGOR | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 20% | since 12/01/2017 |
| TOPPER, AARON | Individual | DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 12/01/2017 |
| RHODE, ROSALINDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/22/2021 |
| WEBER, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2021 |
CMS files one row per role, so the 9 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $502K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525270. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-17, 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.