Frederic Nursing And Rehab Community
205 United Way, Frederic, WI 54837 · For profit - Corporation · 60 certified beds · (715) 327-4297 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 18% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 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 | 11.1% | 16.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.2% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.6% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.2% | 2.7% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 6.7% | 5.7% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.3% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 7.4% | 18.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 27.6% | 16.9% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 90.5% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.2% | 5.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.8% | 24.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.5% | 15.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.6% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 75.0% | 82.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 21.8% | 23.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 17.5% | 15.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.13 | 1.66 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 4.34 | 2.29 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.4% 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 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 73.5% 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 49 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 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | 58.4%CMS range 48.0–69.3 | 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 | 11.3%CMS range 7.4–17.6 | 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 | 73.5% | 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 | 67.3% | 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 | 44.9% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 | 5.8% | 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 | 6.6%CMS range 3.7–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 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 60 beds and averages 52.8 residents a day — about 88% occupied, or roughly 7 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 3.14 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 2.88 hrs/resident/day on weekends vs 3.24 on weekdays — 11% thinner on weekends. RN hours go from 0.79 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% 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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · F2026-05-19 · tag F0725 — failed to have enough nursing staff — widespreadProvide 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
Based on observation, interview and record review, the facility did not ensure sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This has the potential to affect all 54 residents residing at the facility.The facility's Payroll Based Journal (PBJ) triggered for excessively low weekend staffing for Quarter 3 2025 and Quarter 1 2026.Resident Council interviews voiced concerns with short staffing on weekends and longer call light wait times.Staff interviews voiced insufficient staffing levels to meet resident needs.Findings include:Example 1On Sunday, 05/17/26, Surveyors entered facility shortly after 9 AM. Census posting noted 54 residents, 2 licensed nurses, and 5 Certified Nursing Assistants (CNA). Surveyors observed posted staff to be present.Surveyor reviewed the facility's census for Quarter 3 2025 (April 1-June 30) and Quarter 1 2026 (October 1 - December 31). Facility's average daily census is greater than 51. Working schedules noted a licensed nurse on each shift to be consistent…
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 · F2026-05-19 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility did not ensure the facility wide assessment developed by the facility included all relevant details to ensure the facility provided care and services to residents to meet their individual needs within the facility's identified resources. This has the potential to affect all 54 residents.The Facility Assessment did not indicate how resident needs are assessed to determine sufficient staffing levels.Findings include:Facility Assessment Tool, with a reviewed date of 03/09/26, states: .Average daily census: 50-53.Assistance with Activities of Daily Living include an assist of 1-2 for up to 85% of residents and dependent assist up to 15% of residents.Direct care staff needs of 5-6 CNAs on day shift; 4-5 CNAs on evening shift; 2-3 CNAs on overnight shift.The department directors along with the medical records/staffing clerk for nursing develop a block schedule.On 05/19/26 at 10:16 AM, Surveyor interviewed Director of Nursing (DON) B regarding assessing staffing needs. DON B stated staffing is determined using a patient per day (PPD)…
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 · E2026-05-19 · 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 interview, the facility did not ensure that each resident has a safe, clean, comfortable, and homelike environment, including, but not limited to, receiving treatment and support for daily living for 5 (R38, R25, R41, R47, R48) of 6 resident rooms observed and in the hallway on Evergreen unit. Findings include: Surveyor reviewed facility policy titled, Cleaning and Disinfecting Resident Rooms, dated last revised 01/25, states: .Purpose: To provide guidelines for cleaning and disinfection resident's room. Procedure: 1. Housekeeping surfaces (e.g. floors, tabletops) will be cleaned on a regular basis when spills occur, and when these surfaces are visibly soiled. 2. Environmental surface will be disinfected (cleaned) on a regular basis (e.g. daily, three times a week) when surfaces are visibly soiled. 4. Wall, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Surveyor reviewed facility Housekeeping task form titled, Housekeeping Areas of Responsibility, which states: .Housekeeper 2 performs…
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 · E2026-05-19 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility did not make a prompt effort to resolve resident grievances for 4 of 4 residents (R13, R24, R54, and R59).In March 2026, R13 and R24 filed a grievance to report missing clothing. The facility did not complete an investigation, resolve or follow-up on grievance.In April 2026, R54 and R59 filed a grievance to report missing clothing. The facility did not complete an investigation, resolve or follow-up on grievance.Findings include: Facility policy titled, Grievances/Concerns, with a reviewed date of 01/2025, states: Purpose: Providing prompt actions to resolve grievances/concerns and to keep the resident apprised of progress towards resolution.On 05/18/26 at 2:20 PM, Surveyor completed Resident Council interview with residents. R13 and R24 were present and reported that a grievance had been filed with the facility involving missing clothing and R13 and R24 did not receive any follow-up on it. Surveyor asked residents if missing items can't be found, does the facility offer reimbursement or another resolution. R13 and R24 stated…
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 before2026-05-19 · tag F0628 — patternProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure proper discharge documentation was completed for 4 of 15 residents (R) (R56, R54 R8, R9) reviewed for discharge and transfer from the facility.R56, R54 and R9 were missing documentation of notification of the Office of the State Long-Term Care Ombudsman.R8 was missing Bedhold and Transfer notice and the Ombudsman was not notified of the transfer. Findings: The facility policy titled, RESIDENT TRANSFERS AND DISCHARGE Notification reviewed 01/2025 stated in part:The facility will provide written notice in a language the resident or the resident's representative can understand. The notice must also be provided to an immediate family member or legal representative.The facility will utilize and complete all appropriate State forms that include the reason for the discharge, the date of the proposed discharge, the location to which the person will be discharged and their right to appeal the discharge by requesting hearing.The facility will provide the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-19 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility did not promote and facilitate resident self-determination through support of resident choice for 1 of 18 sampled residents (R12). R12 reported his dissatisfaction with the facility not allowing R12 to have his self-purchased coffee maker in R12's room. Findings include: On 05/17/2026 at 10:31 AM, Surveyor interviewed R12 who indicated R12 could not have a coffee maker in his room. R12 reported to Surveyor, R12 had bought his own coffee maker and facility told R12 that R12 could not have R12's coffee maker in the facility. Facility had R12 take coffee maker and place back in the original box and placed in R12's cupboard on top of shelf. R12 stated to Surveyor, I just want my own coffee as the facility coffee sucks. On 05/17/26 at 10:33 AM, Surveyor observed R12 had a coffee maker in an opened box on top shelf in R12's closet in room. On 05/18/26 at 1:13 PM, Surveyor interviewed Certified Nursing Assistant (CNA) H and asked if R12 ever had a coffee maker in his room or requested a coffee maker. CNA H reported to Surveyor that R12 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 · D2026-05-19 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 report to the physician on call of R3's rib pain post fall for 1 of 4 residents (R) reviewed for falls (R3). R3 fell on [DATE] and had multiple complaints of rib pain on 03/23/26, 03/25/26, and 03/26/26. Facility did not notify the physician on call until 03/26/26. Findings include: R3 was admitted to the facility on [DATE] with diagnoses including unspecified hemiplegia affecting left nondominant side, anterior dislocation of left humerus, urinary tract infections, pain in left shoulder, unsteadiness on feet, and hypertensive with congestive heart failure. R3's Minimum Data Set (MDS) assessment, dated 04/15/26, identified R3's Brief Interview for Mental Status (BIMS) scored 1/15, indicating R3 has moderate cognitive impairment. Surveyor reviewed R3's medical record and found R3 sustained a fall on 03/19/26. Surveyor reviewed R3's progress notes relating to R3's fall on 03/19/26: -On 03/19/26 at 1:53 PM, Writer heard resident [R3] yelling…
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 · D2026-05-19 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 failed to protect resident's right to be free from physical and verbal abuse by a resident for 2 of 2 residents (R40 and R57.) R40 was not protected from physical abuse when R57 struck R40 on the face and head multiple times.R57 was not protected from verbal and mental abuse when R40 yelled, threatened, and threw items at R57.Findings include:Surveyor reviewed the facility's policy titled Abuse Prevention Program dated last revised 01/26 which states: .Intent: Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse.Definitions: Resident to Resident Abuse: A resident-to-resident altercation should be reviewed as potential situation of abuse. The facility Administrator and Director of Nursing will initiate an investigation of a potential allegation of abuse between residents. Investigations for potential…
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 · D2026-05-19 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility must ensure each resident is free from unnecessary medications as evidenced by completing adequate behavior monitoring for 2 of 5 residents (R28, R1) reviewed for unnecessary medication reviews.R28 receives 4 psychotropic medications including, Aripiprazole tablet; 10 mg; amt: 10mg; oral Special Instructions: bipolar 1 disorder Once a Morning 08:00 AM 3/31/26, Clonazepam - Schedule IV tablet; 0.5 mg; amt: 0.25mg; oral Special Instructions: GAD (general anxiety disorder) At Bedtime 08:00 PM 3/31/26, Fluoxetine capsule; 40 mg; amt: 2 capsules; oral Special Instructions: GAD/OCD (obsessive compulsive disorder) Once A Morning 08:00 AM 3/31/26, and Mirtazapine tablet; 45 mg; amt: 1 tab; oral Special Instructions: GAD/OCD At Bedtime 08:00 PM 3/31/26 without behavior and effectiveness monitoring. R1 receives Duloxetine (antidepressant) capsule, delayed release; 30 milligrams (mg), once every morning without behavior and effectiveness monitoring. Findings include: The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 when an allegation of abuse was not reported immediately but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials for 1 of 2 resident reviewed for abuse. (Resident (R) 40 and R57). -On 05/16/26, R57 struck R40 along the side of head and top of head from behind multiple times. Facility did not report the physical abuse to state officials. Findings include: Surveyor reviewed facility policy titled, Abuse Prevention Program, dated last revised 01/26, states: .Intent: Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse.Definitions: Resident to Resident Abuse: A resident-to-resident altercation…
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 · D2026-05-19 · 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 interview and record review, the facility did not ensure a thorough investigation was completed to protect R40 and R57 from further potential abuse during a resident-to-resident interaction on 5/16/26 when R40 hit R57 on the head multiple times.Findings include: Surveyor reviewed facility policy titled, Abuse Prevention Program, dated last revised 01/26, states: .Intent: Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse.Definitions: Resident to Resident Abuse: A resident-to-resident altercation should be reviewed as potential situation of abuse. The facility Administrator and Director of Nursing will initiate an investigation of a potential allegation of abuse between residents. Investigations for potential abuse will not be dismissed in cases where either or both residents have a cognitive impairment. During the investigation it will be identified that…
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 · D2026-05-19 · 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 record review and interviews, the facility did not ensure acceptable parameters of nutritional status, such as usual body weight or desirable body weight range by obtaining routine weights routinely for 1 of 2 residents reviewed for nutrition (R28).R28 had an 8% weight loss in a month, which is a significant weight loss. The facility policy titled Unresolved Weight Loss, dated 1/2026, states: A. Definition of Weight LossWeight loss that is unresolved. (5% in 30 days, 7.5% in 90 days, and 10% in 180 days)B. Tips:~Residents that shows significant weight loss must be re-weighed to ensure accuracy.~Perform monthly weight on those residents that show stable weights and weekly weights on those residents that show any weight loss. R28 was admitted to the facility on [DATE], with diagnoses including unspecified protein-calorie malnutrition, and dysphagia. R28's Brief Interview of Mental Status (BIMS) score was 15 out of 15, indicating that R28 is cognitively intact. R28's Minimum Data Set (MDS) assessment,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections with the potential to affect all 23 residents on the Maple hallway in facility.~CNA H used soiled gloved hands to clean care area in R7's room, wipe out the wash basin, and put the basin in a clean garbage bag for next use.~CNA I used soiled hands to assist R7 with eating.~CNA I placed R7's catheter on the floor of the SPA room without barrier, while preparing R7 for his bath.~RN G and CNA F did not carry the dirty linen and garbage bags away from their bodies. The facility policy titled Hand Washing/Hand Hygiene, dated 1/2025, states Practicing [Hand Hygiene] is a simple effective way to present infections by preventing the spread of germs. Wash hands and other skin surfaces when: 1. After immediate contamination with blood, other boy…
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 before2026-05-19 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure each resident is offered a pneumococcal and influenza immunization, unless the immunization is medically contraindicated, or the resident has already been immunized for 1 of 5 residents (R7) reviewed for immunizations.R4 signed a consent for pneumococcal and influenza immunizations and did not receive them.Findings include:Facility policy titled, Influenza Vaccine Policy, with a reviewed date of 01/2025, states: Policy Explanation and Compliance Guidelines: 2. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated.Facility policy titled, Pneumococcal Vaccine Policy, with a reviewed date of 01/2025, states: Policy Explanation and Compliance Guidelines: 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated.R4 was admitted to the facility on [DATE].On 03/05/26, R4 signed a consent to receive a pneumococcal and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 help to prevent the development and transmission of communicable diseases and infections for 2 (R1 and R2) of 4 residents (R) reviewed. R1 tested positive for covid R1 but was not on the facility line list.R2 had Clostridioides Difficile (C-diff); the facility did not document infection control education in R2's medical record prior to discharge. The facility policy titled Outbreak Identification and Management, last reviewed 01/2025, states: This policy is intended to provide guidance in identifying an outbreak timely, measures to take in the event of an outbreak to reduce the spread of infections. Under section labeled Respiratory symptoms and illness, states if one laboratory-confirmed positive case of illness is identified along with other cases of similar acute illness in a unit of a long-term care facility, an outbreak might be…
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 · D2025-07-01 · 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, interview and record review, the facility did not ensure residents received services in the facility with reasonable accommodation of resident needs reviewed for 1 of 12 residents (R), R5. R5's call light was observed to be out of reach and cord not long enough to reach bed. This is evidenced by: R5 was admitted to the facility on [DATE], with pertinent diagnoses of memory deficit following other cerebrovascular disease, age-related osteoporosis, nonexudative age-related macular degeneration, diabetes mellitus type 2, and long-term use of anticoagulants. R5's most recent quarterly Minimum Data Set (MDS) assessment, dated 04/03/25, noted a Brief Interview for Mental Status (BIMS) score of 10/15, indicating moderate cognition impairment, makes self-understood and understands others. R5 is noted to have no impairment in range of motion, uses a walker for mobility, is independent with most ADLs, but requires supervision with shower/bathing. R1 is noted have shortness of breath with exertion and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-01 · 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 observation, interview and record review, the facility did not provide pharmaceutical services that ensure the accurate administering of all drugs and biologicals reviewed for 1 of 1 resident (R), R4. Findings include: Facility policy titled, Self-Administration of Medications reviewed January 2025, states, 1. If a resident request to self-administer medications, a licensed nurse will complete the Self-Administration of medication observation in the electronic health record. R4 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, other lack of coordination, weakness, cataract, allergic rhinitis, and macular cyst. Minimum Data Set (MDS) dated [DATE] an admission assessment documented R4's Brief Interview for Mental Status (BIMS) score of 10/15, meaning cognition is moderately impaired. R4 requires staff supervision for hygiene. On 06/20/25, a self-administration of medication assessment was completed. The assessment was marked R4 does not want to self-administer…
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 before2025-07-01 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure immunizations were administered to 1 of 3 residents (R), R9 reviewed. R9 had a signed consent to receive the influenza, covid-19, and Respiratory Syncytial Virus (RSV) vaccination and never received it. This is evidenced by: Facility policy, titled Influenza Vaccine Policy, with a review date of 01/2025, states in part: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. Policy Explanation and Compliance Guidelines: 2. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine. Facility policy, titled Covid-19 Vaccine Program, with a reviewed date of 01/2025, states in part: It is 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 · Dcited before2025-04-07 · 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 observation, interview and record review, the facility did not ensure the accurate dispensing and administration of all drugs. The facility did not ensure that R2 took their 8:00 AM medications. This is based on 1 of 1 random observation. Findings include: Facility policy titled, Self-Administration of Medications that was reviewed January 2025, states, Residents may noy exercise the right to self-administer medications until IDT [interdisciplinary team] has determined if the resident is safe to self-administer medications. On 04/07/25 at 9:35 AM, Surveyor observed a small plastic cup that held 7 pills sitting on a bedside table in R2's room next to R2's bed. Surveyor observed that room door was open. Medications were within clear sight from the hallway, and R2 was not in the room or bathroom. R2 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction, chronic systolic heat failure, and aphasia following cerebral infraction. On 04/07/25 at 10:05 AM, Surveyor asked Licensed…
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 · E2025-02-18 · tag F0623 — patternProvide 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 interview and record review, the facility did not provide written notice of reason for transfer to the resident or resident representative for 4 of 4 residents (R) reviewed for hospitalization. (R27, R56, R47, R48) Findings include: Example 1 R27 was admitted to the facility on [DATE] with the following diagnoses, in part, type 2 diabetes mellitus with diabetic neuropathy, chronic respiratory failure, weakness and history of falling. On 02/16/25 at 12:34 PM, R27 stated he had a fall in January and was sent to the hospital where they found he had fractured both the tibia and fibula of his left leg. R27 was admitted to the hospital for surgical repair of the fracture. Surveyor reviewed R27's medical record and was able to find a signed bed hold notice for the hospitalization on 01/11/25 but there was no notice explaining in writing the reason for transfer to the hospital. On 02/17/25 at 2:54 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked if they had given a written notice 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 · Dcited before2025-02-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (R49 and R25) observed during medication administration. Staff did not perform hand hygiene before putting on gloves before performing a nursing procedure. Findings: Facility policy titled, HAND WASHING/HAND HYGIENE, reviewed 01/2025 stated in part: Practicing Hand Hygiene is a simple effective way to prevent infections by preventing the spread of germs. Wash hands and other skin surfaces when: .4. Before and after nursing treatments or procedures (dressing changes, catheter insertion, eye drop instillation, etc.) . Example 1 On 02/17/25 at 6:41 AM, Surveyor observed Licensed Practical Nurse (LPN) E administer eye drops to R49. Surveyor noted that after gathering all of the medications and bringing them into R49's room, LPN E did not perform any hand hygiene before putting on gloves and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-01-23 · 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
Based on observation, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety by not wearing hairnets appropriately, and did not ensure proper hand hygiene with food handling. This has the potential to affect all 45 of the 45 residents residing in the facility. Findings include: The facility policy, entitled Dietary Dress Code, dated August 2023, states in part: Hairnets or hair restraints are to be worn. Hair should be completely under the hair restraint with no bangs protruding from any side of one's scalp. The facility policy, entitled Safe Food Handling, dated April 2021, states in part: Associates wash their hands before handling or consuming food. On 01/21/24 at 11:32 AM, Surveyor observed Dietary Aide (DA) M leave the cooking area with gloved hands and walked to the rear of the kitchen where the office and a room where employees keep personal items is located. DA M took a drink from a personal coffee mug and returned to the kitchen. When DA M returned to the cooking area,…
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 · F2024-01-23 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility did not ensure that the mandatory staffing data that had been submitted from 7/1/23-9/30/23 was complete, accurate, and auditable. This has the potential to affect all 45 residents that reside in the facility. This is evidenced by: The Payroll Based Journal (PBJ) Staffing Data Reports that were generated quarterly document that the facility triggered for Excessively low weekend staffing from 7/1/23-9/30/23 for specified dates. The specified dates are as follows: FY (Fiscal Year) Q4 (Quarter 4) 2023 (July 1-September 30). The facility was not able to produce the data that was submitted during this time frame for the specified dates therefore Surveyor was not able to audit the exact document(s) that were submitted. Surveyor reviewed the facility's daily schedule sheets for each date for the last four weeks and all dates had appropriately licensed staff on duty for each shift. Surveyor reviewed the facility's daily census sheets for each date from 07/01/23 to 01/23/24 and all dates had appropriately licensed staff on duty for each…
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 · E2024-01-23 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility did not ensure the privacy and confidentiality of resident medical records. Staff left the Medication Administration Record (MAR) open and visible when unattended during medication administration. This occurred for 4 of 9 residents (R) during medication administration. (R23, R33, R37, and R24) Findings include: Example 1 On 01/22/24 at 5:04 PM, Surveyor approached the medication cart on Maple hall. No one was present by the cart and Surveyor heard a nurse in a room across the hall. The MAR was open with R23's information visible to anyone who walked by the medication cart. At 5:08 PM, Licensed Practical Nurse (LPN) H returned to the medication cart and opened the MAR to R33's information. LPN H took supplies out of the medication cart to check R33's blood sugar and walked down the hall to R33's room. LPN H left the MAR screen open and R33's information was available for anyone to see when LPN H left the medication cart unattended. R33 was unavailable for blood sugar check, so LPN H returned to the medication cart and opened the MAR…
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 before2024-01-23 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility did not maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff did not perform appropriate hand hygiene during cares and medication administration for 2 of 4 resident (R) observations. (R21 and R6) Staff did not sanitize multi-use equipment between residents for 5 of 5 observations. (R21, R198, R5, R38, R15) Findings include: Facility policy entitled, Hand Washing/Hand Hygiene last reviewed 04/23, stated in part: .Wash hands and other skin surfaces when: .2. After removing gloves or other personal protective equipment; 3. After care of each resident; 4. Before and after nursing treatments or procedures . Facility policy entitled, Cleaning/Disinfecting Resident-Care Items and Equipment last reviewed 01/24, stated in part: .Reusable items are cleaned and disinfected between residents (e.g., stethoscopes, durable medical equipment) . On 01/22/24 at 7:59 AM, Surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not provide appropriate care and treatment when a pressure cushion was not placed in wheelchair for pressure relief for 1 of 2 sampled residents (R) R15 who have a pressure injury. Findings include: The facility policy entitled, Pressure Injury Prevention and Care, dated reviewed 01/2022, states in part: Interventions will be implemented, and care planned to prevent pressure injury development or to promote pressure injury resolution. Examples of interventions based on individual resident needs may include the following: #4. G. Repositioning of residents; provision of required assistance as allowed and tolerated. H. Use positioning devices (pillow, blanket, folded sheet, etc.) to prevent skin-on-skin contact when positioning a resident on their side in bed. I. Maintain the head of the bed at the lowest position based on a resident medical condition. J. Encourage and promote the elevation of residents' heels when in bed and prevent residents'…
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 · D2024-01-23 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility did not ensure all drugs and biologicals were stored a in accordance with currently accepted professional principles and did not ensure only authorized personnel had access to medication carts. This occurred for 2 of 2 medication carts/storage rooms observed. During the three-day survey, 2 of 9 observations were made of medication carts left unlocked when unattended and out of view of staff. Findings include: Facility Policy entitled General Dose Preparation and Medication Administration last revised 01/01/22, stated in part: .Facility staff should not leave medications or chemical unattended . Example 1 On 01/22/24 at 7:14 AM, Surveyor observed Licensed Practical Nurse (LPN) F leave the medication cart unlocked, enter R28's room and administer medications to R28. Surveyor observed a vitamin D bottle with pills inside lying on top of the medication cart unattended. On 01/22/24 at 7:42 AM, Surveyor observed LPN F at the medication cart reviewing medications for R24. LPN F walked down the hallway to R38's room leaving the 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.
- No harm found · Ccited before2025-07-01 · tag F0628 — widespreadProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility did not ensure residents/representatives were notified of the rate to reserve the resident's bed and was not documented in the Wisconsin Bed Hold and Notice of Transfer. This has the potential to affect all 53 residents. R4, R8, and R11 received a bed hold notice with no daily rate documented. This is evidenced by: Facility's policy titled Bed Hold with reviewed date of 01/25 read in part, .2. The facility shall provide the bed hold policy Acknowledgement to the resident or the resident representative with any resident initiated therapeutic leave or transfer to alternative healthcare community including a hospital admission. This acknowledgement will provide information to the resident and/or resident representative that explains the duration, the reserved bed payment policy and also facility permitting return of the resident to the next available bed .4. Bed-hold days in excess of our State Medicaid Plan are considered non-covered services. A resident will be required to pay for any additional days that he/she wishes the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ATRIUM CENTERS — 26 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 3 of 5 | 3.4 | -0.4 vs chain |
| Quality measures | 3 of 5 | 3.7 | -0.7 vs chain |
The other 25 homes this chain runs (chain average 3.0★, 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 |
|---|---|---|---|---|
| ORION OPERATING SERVICES LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/01/2007 |
| BAILEY, ESSEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 74% | since 12/01/2007 |
| FINNEY, DONALD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 25% | since 12/01/2007 |
| LINEHAN, PATRICIA | Individual | W-2 MANAGING EMPLOYEE | — | since 12/01/2007 |
| FERKANY, JAMES | Individual | CORPORATE OFFICER | — | since 08/01/2018 |
| ATRIUM CENTERS MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2007 |
| ALBRIGHT ROSS, SUSAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2018 |
| LOCKHART, DENNIS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/2018 |
CMS files one row per role, so the 10 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $910K paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 525665. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-19, 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.