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Edenbrook of Green Bay

2961 St Anthony Dr, Green Bay, WI 54311 · For profit - Corporation · 90 certified beds · (920) 468-0861 Medicare & Medicaid certified

Call the home — (920) 468-0861 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Urgent care / clinic
2900 Curry Lane · (920) 272-3380 · Call to confirm hours
Pharmacy
Walgreens1.6 mi
2204 University Ave · (920) 469-5516 · Call to confirm hours
Grocery
2430 University Avenue
Park
2420 Nicolet Dr · (920) 465-5032 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.1%16.1%15.4%better
Long-stay residents who lose too much weight2.7%5.1%5.4%better
Long-stay residents with a catheter left in their bladder2.4%2.1%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.4%2.7%2.0%worse
Long-stay residents with depressive symptoms6.5%5.7%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.0%3.3%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened16.1%18.4%16.1%typical
Long-stay residents on antianxiety or hypnotic medication17.3%16.9%18.9%typical
Long-stay residents given the seasonal flu vaccine96.8%95.0%95.3%typical
Long-stay residents with pressure ulcers5.4%5.0%4.7%worse
Long-stay residents with worsening bladder/bowel control28.9%24.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table6.9%15.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine84.3%82.2%79.4%typical
Short-stay residents rehospitalized after admission15.8%23.1%22.6%better
Short-stay residents with an outpatient ER visit12.8%15.5%12.0%typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

47.5% 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 57 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.5%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
54.0%U.S. median 56.6%
Met the expected recovery
0.47U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 54.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 37 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 0.47 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF47.5%CMS range 34.8–58.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.8–15.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge54.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge46.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge43.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified72.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.3%CMS range 3.8–13.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.72
RN hours/ resident / day
0.83
LPN hours/ resident / day
2.13
Aide hours/ resident / day
3.68
Total nurse hours/ resident / day
0.37
RN hoursweekends
51.2%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 90 beds and averages 70.6 residents a day — about 78% occupied, or roughly 19 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.68 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 3.33 hrs/resident/day on weekends vs 3.82 on weekdays — 13% thinner on weekends. RN hours go from 0.86 to 0.37 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

4
deficiencies at the latest standard inspection (2025-08-27)
8
at the previous standard inspection (2024-07-17)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · Gcited before2024-02-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the provision of care and treatment in accordance with professional standards of practice for 2 Residents (R) (R7 and R6) of 8 sampled residents. The facility did not follow their policy or clarify a physician's order related to blood sugar parameters for R7. As a result, R7 was sent to the emergency room (ER) for treatment of hypoglycemia (low blood sugar) on 11/26/23. The facility did not ensure physician orders were followed for R6's PICC (peripherally inserted central catheter) line. Findings include: The facility's Care of the Diabetic Resident policy, dated 8/22/23, indicates: Purpose: To assist the resident to establish a balance between diet, exercise, and insulin; prevent recurrence of hyperglycemia/hypoglycemia; recognize, assist, and document the treatment of complications commonly associated with diabetes; .a. Signs and symptoms of hypoglycemia usually have a sudden onset and may include the following: .v. pale cool moist skin;…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure assessments and daily skilled/alert charting was completed for 2 residents (R) (R7 and R12) of 13 sampled residents.R7's medical record did not contain assessments on 5/14/26 and 5/19/26 to ensure R7 was monitored and evaluated post-fall.R12 was admitted to the facility without initial nursing assessments to determine R12's required level of assistance.Findings include:The facility's Fall Prevention, Post Fall, and Communication policy, dated 1/21/26, indicates: Purpose: To promote resident safety by identifying fall risk, implementing individualized fall-prevention interventions, ensuring timely post-fall evaluation, and reviewing outcomes to prevent recurrence .Post fall response: .2. Monitoring and re-evaluation: Document on resident's condition at a minimum of every shift for 72 hours. Staff should document relevant post-fall clinical findings, such as vital signs, pain, swelling, bruising, and changes in function or cognitive status.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-20 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 monitoring of high-risk medications for 3 residents (R) (R7, R11, and R12) of 4 sampled residents.R7 was prescribed oral vancomycin (an antibiotic medication) for clostridioides difficile (C. diff) infection. R7's medical record did not indicate staff monitored R7 for adverse reactions to the high-risk medication.R11 was prescribed IV cephalexin (an antibiotic medication) for cellulitis. R11's medical record did not indicate staff monitored R11 for adverse reactions to the high-risk medication.R12 was prescribed IV ceftriaxone sodium (an antibiotic medication) for osteomyelitis and sepsis. R12's medical record did not indicate staff monitored R12 for adverse reactions to the high-risk medication.Findings include:The facility's Policy and Procedure Alert Charting, revised 11/13/24, indicates: Purpose: To provide guidance for documentation in the medical record for situations that meet the criteria of a change in condition, and…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-20 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 timely laboratory services for 1 resident (R) (R2) of 3 sampled residents. Nurse Practitioner (NP)-E ordered a potassium lab to be drawn for R2 by 3:00 PM on 3/25/26 due to a critical potassium blood level. The lab was not drawn until 3/26/26 at approximately 9:00 AM. Findings include: The facility's Physician Orders policy, revised 11/13/24, indicates physician orders will be transcribed and implemented in accordance with professional standards. On 5/19/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including paraplegia, pneumonia, diabetes, cirrhosis of the liver, and anxiety. R2's Minimum Data Set (MDS) assessment, dated 4/13/26, stated R2's Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating intact cognition. R2 discharged from the facility on 5/6/26. Surveyor reviewed R2's Treatment Administration Record (TAR) and lab reports. Lab results, dated 3/25/26 at…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-08-27 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, had a national certification for food service management and safety from a national certifying body, or who had an associate's or higher level degree in food service management or hospitality. This practice had the potential to affect all 70 residents residing in the facility. Findings include:On 8/26/25, Surveyor requested to review Dietary Manager (DM)-R's certification. On 8/26/25 at approximately 1:00 PM, Surveyor received paperwork from Nursing Home Administrator (NHA)-A that included a screenshot of test results for DM-R. The paperwork for DM-R indicated DM-R did not pass the dietary manager certification test and was not certified. Surveyor interviewed NHA-A who indicated DM-R did not pass the test and was not able to take the test again for 90 days. NHA-A was unsure when DM-R failed the test. On 8/26/25 at 2:18 PM, Surveyor interviewed NHA-A who indicated NHA-A 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-27 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R2, R3, and R59) of 11 sampled residents.R2 was on isolation precautions for Clostridium Difficile (C. diff). During observations of care, staff did not don the appropriate personal protective equipment (PPE) and complete hand hygiene prior to entering and exiting R2's room and did not dispose of soiled linens in accordance with the facility's policy. In addition, R2's Kardex (an abbreviated care plan used by nursing staff) did not indicate R2 was on isolation precautions and R2's medical record did not contain Clostridium Difficile as a diagnosis.Staff did not don the appropriate PPE while completing a dressing change and nephrostomy tube care for R3.R59 had a wound. Enhanced barrier precautions (EBP) were not initiated in a timely manner. In addition, staff did not adhere 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-27 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not maintain dignity during meal time for 3 residents (R) (R22, R29, and R59) of 4 sampled residents.R22, R29, and R59 required assistance with eating. On 8/26/25, staff moved between R22, R29, and R59 (who were at different tables) while providing assistance with breakfast and stood while feeding them.Findings include:From 8/25/25 to 8/27/25, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, dementia, cancer, end stage renal disease, diabetes, and hemiplegia/hemiparesis. R22's Minimum Data Set (MDS) assessment, dated 6/23/25, indicated R22 was rarely or never understood.From 8/25/25 to 8/27/25, Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE] and had diagnoses including muscular dystrophy, calorie deficit at risk for malnutrition, and Friedreich's ataxia. R29's MDS assessment, dated 8/11/25, had a Brief Interview for Mental…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 3 residents (R) (R65, R52, and R9) of 3 sampled residents.Staff did not update the provider with a weight gain of 3 pounds or more in one day or 5 pounds or more in one week as ordered for R65, R52, and R9. Findings include: The facility's Heart Failure policy, dated 3/19/24, indicates: .2. In addition, the nurse will assess and document/report the following: .b. Daily weights or as ordered by the provider .i. Call for weight gain of 3 pounds or greater in 24 hours or 5 pounds in one week or as directed by the provider .d. Provider will be updated with changes in condition . 1. From 8/25/25 to 8/27/25, Surveyor reviewed R65's medical record. R65's most recent admission to the facility was on 7/15/25. R65 had diagnoses including chronic systolic congestive heart failure (CHF), acquired absence of left leg below knee, and diabetes mellitus type 2.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-18 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management 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 and resident interview and record review, the facility did not ensure pain medication was provided timely for 1 resident (R) (R4) of 3 sampled residents.R4 received Hospice services and had an order for as needed (PRN) morphine for pain. On either 7/8/25 or 7/20/25, R4 requested PRN pain medication. R4 did not receive the medication timely. Findings include:The facility's Pain Management and Assessment policy, revised 4/25/25, indicates: The purpose of this policy is to develop a standardized method for assessing, monitoring, evaluating, managing, and documenting pain in both cognitively intact and impaired residents. Residents will receive necessary comfort, exercise greater independence, and enhance dignity through optimizing their ability to perform activities of daily living. On 8/18/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including lung cancer, brain cancer, encounter for palliative care, chronic obstructive pulmonary disease…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-06 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and record review, the facility did not ensure medication was dated when opened and stored appropriately for 2 residents (R) (R9 and R10) of 3 residents observed during medication administration. In addition, staff left a medication cart unlocked and unattended and R11's Medication Administration Record (MAR) exposed during medication administration. This practice had the potential to affect more than 4 of the 74 residents residing in the facility. On 6/6/25, Surveyor observed Licensed Practical Nurse (LPN)-D prepare and administer timolol maleate ophthalmic solution 0.5 % eye drops to R9. The eye drops did not contain an open date. On 6/6/25, Surveyor observed LPN-D prepare and administer 5 units of Basaglar KwikPen (insulin) 100 units/milliliter (ml) to R10. The insulin pen did not contain an open date. On 6/6/25, Surveyor noted a medication cart was left unlocked and unattended when LPN-D entered R11's room to administer medication. LPN-D also did not ensure a computer on top of the medication cart that displayed R11's 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-06 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 provide pharmacy services to ensure the accurate and safe administration of medication for 1 resident (R) (R10) of 3 residents observed during medication administration. R10 had an order for insulin aspart injection solution 100 units/milliliter (ml) inject 5 units subcutaneously before meals for hyperglycemia related to type 2 diabetes. On 6/6/25, Licensed Practical Nurse (LPN)-D incorrectly administered 5 units of Basaglar KwikPen (long-acting insulin) 100 units/ml to R10. Findings include: The facility's Administering Medications Policy & Procedure, revised 1/22/24, indicates: Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure: .4. Medications shall be administered per provider's written/verbal orders upon verification of the right medication, dose, route, time, and positive verification of the resident's identity when no…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · Dcited before2025-06-06 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and record review, the facility did not ensure staff followed proper infection control practices for 4 residents (R) (R9, R10, R11, and 14) of 4 sampled residents. On 6/6/25, Licensed Practical Nurse (LPN)-D did not complete hand hygiene before preparing or after administering medication to R9, R10, and R11. On 6/6/25, Certified Nursing Assistant (CNA)-E placed wash cloths in an unsanitized sink and ran water over them. CNA-E then wrung out the wash cloths, hung them over the side of the sink, and used them to complete pericare for R14. Findings include: The facility's Hand Hygiene policy, revised 5/8/24, indicates: Purpose: To provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections. Procedure: .2. The use of gloves does not replace hand hygiene. 3. Hand hygiene is always the final step after removing and disposing of personal protective equipment (PPE) .Washing Hands with Soap and Water: 1. Staff will perform hand hygiene by washing hands 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R5) of 10 sampled residents received assistance with a request in a timely manner. On 2/26/25, R5's call light was activated at 6:46 AM. Certified Nursing Assistant (CNA)-G turned R5's call light off at 7:12 AM after R5 requested a cup of coffee. R5 was not provided coffee until R5's breakfast tray was delivered at 8:10 AM. Findings include: On 2/26/25, Surveyor reviewed R5's medical record. R5 had diagnoses including spinal stenosis, type 2 diabetes mellitus, choric obstructive pulmonary disease (COPD), anxiety, and chronic pain syndrome. R5's most recent Minimum Data Set (MDS) assessment, dated 12/6/24, had a Brief Interview for Mental Status (BIMS) score of 13 out 15 which indicated R5 had intact cognition. The MDS assessment also indicated R5 required set up assistance for eating. R5's plan of care indicated R5 had an activity of daily living (ADL) deficit related to weakness and impaired mobility. On 2/26/25 at 6:46 AM, Surveyor noted R5's call light was activated.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not provide the necessary care and treatment to maintain the highest practicable well being for 2 residents (R) (R7 and R10) of 10 sampled residents. Staff did not consistently complete daily weights as ordered for R7 and R10. Findings include: The facility's Heart Failure policy, dated 3/19/24, indicates: .The nurse will assess and document/report the following: a. Daily vital signs or as ordered by the provider; b. Daily weights or as ordered by the provider .i. Call for weight gain 3 pounds or greater in 24 hours or 5 pounds in one week or as directed by the provider .5. The physician will help identify individuals at risk for having cardiac decompensation, for example, because of arrhythmia .chronic obstructive pulmonary disease . 1. On 2/26/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure (CHF) and diabetes. R7's most recent Minimum Data Set (MDS)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure the resident environment was as free of accident hazards as possible for 2 residents (R) (R9 and R10) of 8 sampled residents. R9's care plan contained an intervention for the assistance of two staff and a full-body (Hoyer) lift for transfers. The intervention was not consistently followed. R10's care plan contained an intervention for the assistance of two staff and a sit-to-stand (EZ Stand) lift for transfers. The intervention was not consistently followed. Findings include: The facility's Sit-to-Stand Mechanical Lift Policy, revised 8/22/23, indicates: To assist residents with transfers who are able to bear weight with some assistance. Employees will use the sit-to-stand mechanical lift per policy to ensure safety for the resident and the employee .1. Sit-to-stand mechanical lift will be used with two caregivers . The facility's Total Mechanical Transfer Policy, revised 8/22/23, indicates: To safely transfer residents who have…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 4 residents (R) (R49, R3, R22, and R27) of 5 sampled residents. The facility did not clean continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) machines per manufacturer's instructions and the facility's policy. Findings include: The facility's CPAP/BiPAP Use policy, with a revision date of 6/15/23, indicates: To provide guidelines for the use of CPAP/BiPAP therapy for the treatment of the following conditions: Obstructive sleep apnea .history of respiratory failure .Procedure: .6. Filter on CPAP/BiPAP will be replaced based on manufacturer's recommendations. The Air Fit ResMed Mask User Guide indicates: When to replace CPAP supplies .To get the most out of your sleep apnea therapy, using your CPAP machine is only half the battle. The other half is making sure you inspect and replace your supplies as often as needed to maximize…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-17 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 menu serving sizes were followed for therapeutic and mechanically altered diets for 5 residents (R) (R69, R12, R62, R11, and R2) of 19 sampled residents. Staff served smaller portions than the extended menu indicated for R69 who had an order for double protein and R12, R62, R11, and R2 who were prescribed mechanically altered diets. Findings include: The facility's Diet and Diet Orders policy, with a revision date of 12/11/23, indicates: All diets will be prescribed by the attending physician. The dietitian will review diets for accuracy and therapeutic goals and recommend changes to the physician as deemed appropriate .When necessary, the attending physician will order therapeutic or mechanically altered diets to address certain diseases and/or facilitate oral intake .The purpose of this policy is to provide consistency and accuracy in all diets provided to our residents and patients .Procedure: .5. Specific requests such as high protein .will be assessed by the dietitian and adjusted 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-17 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 1 resident (R) (R54) of 19 sampled residents had a self-administration of medication assessment or a physician's order to self administer medication. On 715/24, Surveyor observed medication left at R54's bedside. R54 did not have a self-administration of medication assessment or a physician's order to self-administer medication. Findings include: The facility's Medication Self Administration policy and procedure, revised on 2/12/24, indicates: 1. The resident shall have a screen completed by a licensed nurse to determine factors that may impact the safe administration of medication .3. Or with supervision/cueing or after set up, shall have a physician order to do so .5. Medications to be self-administered shall be secured in a locked area in the resident's room or stored in the medication cart for provision to the resident to self-administer. 1. On 7/15/24, Surveyor reviewed R54's medical record. R54 was admitted…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained free of accident hazards for 1 resident (R) (R48) of 1 resident reviewed for smoking. R48 was known by the facility to smoke. The facility allowed R48 to carry R48's smoking materials in R48's wheelchair. Findings include: The facility's Smoking and E-Cigarettes Policy and Procedure Addendum: Facility Specific Smoking Plan states: Smoking items will be stored in the following locations: First floor nurses' station med room and second floor nurses' station med room. All residents must turn in smoking materials to their nurse after each use. Smoking materials are prohibited in resident rooms. On 7/15/24, Surveyor reviewed R48's medical record. R48 was admitted to the facility on [DATE] with diagnoses including diabetes type 2 with neuropathy, left and right below knee amputation, weakness, and dementia. R48's Minimum Data Set (MDS) assessment, dated 7/4/24, had a Brief Interview 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not provide appropriate care and services to prevent urinary tract infections (UTIs) for 2 residents (R) (R47 and R49) of 10 residents with indwelling catheters. R47 and R49's uncovered catheter drainage bags were observed in contact with the floor. Findings include: The facility's Catheter Care Policy and Procedure, with a revision date of 2/27/18, indicates: Staff will maintain consistent and adequate hygiene standards for residents with an indwelling catheter in order to maintain comfort, function, and infection prevention and other complications. The facility's Foley Catheter Management Policy and Procedure, with a revision date of 11/4/20, indicates: .4. Catheter bags will be covered at all times .6. Correct positioning of catheter will be maintained .References: Guideline for the Prevention of Catheter Associated Urinary Tract Infections 2009. The Guideline for the Prevention of Catheter Associated Urinary Tract…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-17 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 medications were labeled and stored appropriately for 3 residents (R) (R21, R32, and R9) of 8 sampled residents. During observations of medication administration, Surveyor observed staff administer open and undated medications to R21 and R32. On 715/24, Surveyor observed wound care treatment solutions and acetic acid stored on R9's bedside table which was not in accordance with the facility's policy. Findings include: The facility's Medication Storage Policy, with a revision date of 2/12/24, indicates: 2. Drug containers having .missing labels will be returned to the pharmacy for proper labeling before storing. 3. No discontinued, outdated, or deteriorated medications should be available for use in the facility. All such medications are destroyed per policy. 4. Expired medications are to be removed from medication carts prior to or at the time of expiration. Multi-Dose Vials: 1. Vials must be dated upon opening.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-17 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 2 residents (R) (R51 and R54) of 19 residents. R51 had wounds that required wound care and was not on enhanced barrier precautions (EBP). R54 had an indwelling catheter and was not on EBP. Findings include: The facility's Enhanced Barrier Precautions Policy and Procedure, dated 3/26/24, indicates: Enhanced Barrier Precautions require gown and glove use for residents with a novel or targeted multi-drug resistant organism (MDRO) or any resident with a wound or indwelling medical device during specific high-contact resident care activities. High-contact resident care activities include: dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use of a device; central line, urinary…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-17 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop 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 staff and resident interview and record review, the facility did not ensure vaccinations were administered for 1 resident (R) (58) of 5 sampled residents. The facility did not administer R58 the PCV20® vaccine after R58 signed a consent form to receive the vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance®) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults 65 years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-04 · tag F0562 — isolated
    Provide immediate access to any 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 staff interview and record review, the facility did not permit immediate access to a resident by a representative of the protection and advocacy systems, as designated by the state, and as established under the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (42 U.S.C. 15001 et seq) for 1 Resident (R) (R2) of 5 sampled residents. The facility denied access to resident information to a representative from APS (Adult Protective Services) and a representative from the Department of Corrections (DOC) (Probation Officer). Findings include: On 3/4/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis and generalized anxiety disorder. R2's Minimum Data Set (MDS) assessment, dated 2/11/24, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. R2's medical record indicated R2 was responsible for R2's healthcare decisions. R2's medical record did 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-27 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview and record review, the facility did not ensure a resident representative was notified of a change in condition and/or treatment for 2 Residents (R) (R1 and R4) of 8 sampled residents. R1 experienced multiple episodes of syncope (fainting) as well as a change in wound treatment. The changes were not communicated to R1's activated Power of Attorney for Healthcare (POAHC). R4 experienced signs and symptoms of a urinary tract infection (UTI) on two occasions that required a change in medical treatment. In addition, R4 experienced signs and symptoms that required the need for laboratory testing and an X-ray. The changes were not communicated to R4's activated POAHC. Findings include: The facility's Change in Condition policy, revised 7/6/21, indicates: 1. The Physician and Durable Power of Attorney (POA)/responsible party will be notified when there has been a change that is sudden in onset, a change that is a marked difference in usual sign/symptoms and/or the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-27 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 staff interview, the facility did not ensure laboratory services were provided timely for 1 Resident (R1) of 8 sampled residents. R1's primary care provider ordered a urinalysis (UA) on 1/15/24. The UA was not completed until 1/19/24. Findings include: On 2/26/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including right femur fracture, kidney disease, congestive heart failure (CHF), Parkinson's disease, and dementia. R1's most recent Minimum Data Set (MDS) assessment, dated 12/18/23, indicated R1's cognition was severely impaired and R1 was dependent upon staff for activities of daily living (ADLS). R1's Power of Attorney (POA) was activated upon admission. On 2/26/24, Surveyor reviewed R1's medical record and noted the following: A note written by Nurse Practitioner (NP)-C, dated 1/15/24, indicated that although R1 did not meet the criteria for a UA with culture, NP-C would order one based on R1's history of urinary tract…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-07-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and record review, the facility did not ensure safe food handling practices were implemented. This had the potential to affect all 64 residents residing in the facility. Food items intended for resident consumption were without required labels and dates and some were past the manufacturer's use-by date. Nourishment room refrigerator temperature logs were incomplete. The main kitchen and nourishment room refrigerators were not clean. Findings include: Food Labeling: The Wisconsin Food Code indicates at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety 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) and (F) 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 premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R44) of 1 sampled resident was provided oral hygiene assistance. R44 reported staff did not offer R44 oral care which was verified during an observation on 7/26/23. Findings include: The facility's Activities of Daily Living (ADL) policy, dated 3/15/21, contained the following information: 1. A resident will be given the appropriate treatment and services to maintain or improve his or her ability to carry out activities of daily living. 2. The facility will provide care and services for the following activities of daily living: Hygiene .oral care. ADLs will be provided per the resident's individualized plan of care. R44 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive, obesity, protein calorie malnutrition, and gastroesophageal reflux disease (GERD). R44's most recent Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-26 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management 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 and resident interview, and record review, the facility did not ensure effective pain management was provided for 1 Resident (R) (R216) of 3 sampled residents. R216 was not provided effective pain management from 7/21/23 through 7/24/23. Findings include: The facility's Pain Management and Assessment policy, revised 4/27/22, contained the following information: Nursing staff will identify individuals who have pain or who are at risk for having pain. This includes a review of each person's known diagnoses and conditions that commonly cause or predispose to pain .It also includes a review for any treatments that the resident currently is receiving for pain, including complementary (non-pharmacologic) treatments. From 7/24/23 through 7/26/23, Surveyor reviewed R216's medical record. R216 was admitted to the facility on [DATE] with a diagnosis of status post right hip hemiarthroplasty after fracture of right femoral neck on 7/20/23. R216's daily skilled charting indicated R216 was alert and oriented.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-26 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 1 Resident (R) (R50) of 5 sampled residents was monitored for adverse consequences of a high risk medication. R50 was prescribed Xarelto (an anticoagulant). R50 did not have a care plan that addressed Xarelto use or contained interventions to monitor for adverse consequences of the high risk medication. Findings include: The facility's Care Plan-Baseline and Comprehensive policy, revised 6/20/23, contained the following information: Purpose: To ensure that each resident receives care individualized to him or herself and that goals and approaches for care are communicated to all parties including caregivers, the resident, and the resident's representative .10. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 11. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident. 12. Assessments 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-02-26 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and record review, the facility's nursing staff postings did not contain accurate data and were not retained for 18 months. This practice had the potential to affect all 68 residents in the facility. The facility did not update the daily nursing staff postings when there were schedule changes. The nursing staff postings contained numbers for staff in a full shift row despite the fact staff only worked a partial shift. In addition, the facility did not retain the postings for 18 months. Findings include: The facility's Staff Posting policy, revised 10/19/23, indicates: The facility shall post daily the actual hours and total number of hours worked by licensed and unlicensed nursing staff who are directly responsible for resident care on each shift in the facility. On 2/26/25 at 4:51 AM, Surveyor observed a nursing staff posting on the first floor which contained 7 rows and 6 columns. The rows indicated shift times and the columns indicated staffing positions. Surveyor noted the 10:00 PM to 6:00 AM row for 2/25/26 indicated there were 3 Certified…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to EDEN SENIOR CARE — 21 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.6+0.4 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 2 of 53.1-1.1 vs chain
Quality measures 4 of 53.3+0.7 vs chain
The other 20 homes this chain runs (chain average 2.6★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
FEINSTEIN, DANIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST12%since 12/04/2018
LIFSICS, CHANNIEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST9%since 12/04/2018
POLSTEIN, MORDECHAIIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL16%since 12/01/2018
STESEL, MAXIMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST45%since 12/04/2018
MALIK, BOBBYIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2020
RICE, PAMELAIndividualCORPORATE OFFICERsince 03/01/2017
DENNISON, MEGANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
MAUER, DOVIEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2018

CMS files one row per role, so the 11 rows in the source record cover these 8 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.

$7.8M
Net patient revenuemost recent cost report
+7.6%
Operating marginrevenue minus expenses
$807K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 6%Other / private 35%

This home reported $807K paid to related parties — landlords or management companies under common ownership — equal to about 11% 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

$312per resident / day
operating cost
$9,491per month
≈ monthly operating cost
$338per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WI

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.

Typical monthly cost in Wisconsin
$10,646/mo
Nursing home (semi-private)
$12,319/mo
Nursing home (private)
$6,540/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525307. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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