Rock Haven
3400 N Cty Trk Hwy F, Janesville, WI 53547 · Government - County · 128 certified beds · (608) 757-5076 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)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (23% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $42,560 in federal fines (most recent 2025-06-18)
- its payroll-based staffing score sits well above its independent inspection score
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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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.
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 | 16.1% | 16.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 8.8% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.4% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.3% | 2.7% | 2.0% | better |
| Long-stay residents with depressive symptoms | 8.0% | 5.7% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.1% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.6% | 18.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.2% | 16.9% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 89.4% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.8% | 5.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.4% | 24.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.4% | 15.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.2% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 79.7% | 82.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 19.7% | 23.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 22.1% | 15.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.47 | 1.66 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.98 | 2.29 | 1.80 | typical |
‡ 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.
45.8% 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 59 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 47.2% 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 36 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 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% 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 | 45.8%CMS range 34.5–60.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 6.1–13.9 | 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 | 47.2% | 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 | 41.7% | 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 | 27.8% | 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 | 63.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 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 | 0.0% | 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 | 7.2%CMS range 3.6–12.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 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 128 beds and averages 90.4 residents a day — about 71% occupied, or roughly 38 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 5.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.51 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.64 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 5.41 hrs/resident/day on weekends vs 5.94 on weekdays — 9% thinner on weekends. RN hours go from 1.56 to 1.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 23% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · J2025-06-18 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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, record review, and facility policy review, the facility failed to prevent significant medication errors for 2 out of 7 residents (R1 and R4) reviewed for medication administration out of a total sample of 15 residents. R1 was administered medications prescribed for R2 on 04/16/25. This medication error caused R1 to be transferred to the hospital due to an accidental medication overdose. The facility's failure to prevent significant medication errors, continually assess the resident after the medication error, and immediately notify the physician of the medication errors created a finding of immediate jeopardy that began on 4/16/25. Surveyor notified the Administrator and Assistant Director of Nursing (ADON) of the immediate jeopardy on 6/5/25 at 10:20 AM. The immediate jeopardy was removed on 6/4/25, however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by the following example. R4 was administered R3's nebulizer…
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 · F2026-01-29 · 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 and interview, the facility did not prepare and distribute food in accordance with professional standards for food service safety. This has the potential to affect all 91 residents. Surveyor observed a cook take the temperatures of food without properly cleaning the food thermometer probe. Evidenced by: Facility policy, entitled Food Temping, dated 10/8/25, states, in part: Purpose: To provide every resident adequate nutrition in a safe environment. Store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Policy: Rock Haven will provide residents with meals that are safe. following infection prevention measures. Procedure: Service: . 9. [NAME] food to proper temperature. 10. Use a clean thermometer. On 1/26/26 at 12:16 PM, Surveyor observed [NAME] D taking the temperatures of the food in the steam table prior to lunch being served in the dining room. Surveyor observed [NAME] D cleaning the food thermometer probe off with a napkin prior to inserting the thermometer probe into the various foods. 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 · E2026-01-29 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
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 establish an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 4 of 4 supplemental residents (R79, R43, R17, and R27). R79, R43, R17, and R27 were treated with antibiotics without meeting Loeb Criteria. R79, R43, R17, and R27 did not have an antibiotic stewardship conversation with the Provider. This is evidenced by: The Facilities Antibiotic Stewardship Policy and Procedure dated 10/20/25 documents in part: .Antibiotic stewardship will include an assessment process, use of evidence-based criteria, efforts to identify the microbe responsible for disease, selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate dosing, route, and duration of antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed. Example 1 R79 is on the line list for UTI (urinary tract infection), listed symptoms are cloudy urine with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-29 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility did not ensure to develop and implement written policies and procedures that: S483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 8 staff reviewed for background checks.MT C (Maintenance Tech) did not have a background check completed every 4 years.This is evidenced by:The facilities Policy and Procedure for Background Checks states in part. Wisconsin law requires caregiver background checks using a Background Disclosure Form mandating completion at hire and every four years. MT C (Maintenance Tech) hire date was 12/14/20. His last completed background check was completed on 1/28/26. MT C should have had a background check completed by 12/14/24.On 1/28/26 at 4:45 PM surveyor interviewed NHA A (Nursing Home Administrator) and asked if background checks are supposed to be completed every 4 years. NHA A replied yes.On 1/29/27 at 8:26 AM surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if background check information 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 · D2026-01-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 22 sampled residents (R53). R53 has a diagnosis of Congestive Heart Failure and the facility failed to recognize R53's severe weight gain as a significant change in condition, and the PCP was not notified. Staff failed to re-weigh, conduct assessments, and put appropriate interventions into place regarding R53's weight gain and increased edema. This is evidenced by: Facility policy titled, Weight Management, dated 6/10/15, states, in part, Procedure: . Residents will be weighed monthly unless otherwise ordered by the Physician or deemed necessary by the Interdisciplinary Team. Re-Weights will be obtained as soon as possible for any resident with a +/- five (5) lb. change from the previous weight. This weight should be documented in the residents record as a re-weight. Nursing staff will notify the physician and responsible parties…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-29 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 4 Sampled residents (R47) reviewed for trauma informed care. R47 did not have a Trauma Informed Care Assessment completed upon admission. Psychiatric notes written while admitted to the facility indicate R47 has a history of nightmares related to combat he experienced in Vietnam. R47's trauma was not identified, and no care plan approaches to mitigate triggers to prevent re-traumatization were put into place. This is evidenced by: The facility policy entitled, Trauma Informed Care, dated [DATE], states in part: . A Trauma Informed Care Information sheet will be provided in each new admission booklet. Social [NAME] will briefly review…
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 · D2025-08-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, facility document and policy review, the facility failed to reassess the risk of elopement and identify interventions to prevent a resident from exiting the facility through the bedroom window for 1 (Resident #1) of 5 residents reviewed for accidents. Resident #1 was observed by staff packing their belongings in a bag and saying they were leaving the facility but was not reassessed for the risk of elopement. Resident #1 exited the facility on 07/03/2025 at 12:05 AM, unnoticed and unsupervised by staff, and was found after approximately ten minutes in the bushes outside the resident's bedroom window. Findings included: The facility policy titled, Elopements, revised 07/09/2025, indicated, III. Definitions: Elopement behavior: Making verbalizations about wanting to leave, talking about going home, packing belongings, opening windows, and opening doors. IV. Elopement: When a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves a caregiving 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.
- Potential for harm · D2025-06-18 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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, record review, and document review, the facility failed to follow professional standards for 1 of 3 residents (R8) reviewed for Power of Attorney (POA) status out of a total sample of 15. Findings include: Review of R8's undated Face Sheet, located under the Face Sheet tab in the electronic medical record (EMR), indicated R8 was admitted to the facility on [DATE] with diagnoses that included fracture of the left pubis, cancer, and Alzheimer's disease. Review of R8's admission Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of [DATE], indicated R8 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated R8 was moderately cognitively impaired. Review of R8's Advance Directive including Power of Attorney for Health Care, which was provided by the facility and signed by R8 on [DATE], revealed R8's spouse had been selected as the resident's health care agent. The form recorded, . If the health care agent is…
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 · D2024-09-19 · 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 review of facility policy, record review, and interview, the facility failed to ensure two residents (R) (R16 and R43) out of 22 residents reviewed for abuse/neglect were protected from potential physical abuse. The facility failed to ensure R16 was protected from potential physical abuse by Certified Nurse Aide (CNA) 2 by continuing to schedule CNA2 on the same unit that R16 resides. As a resident, R16 continued to be fearful. The facility failed to prevent physical and verbal abuse of R43 in which CNA3 prevented R43 from rising from a chair and was potentially verbally abusive during this same interaction by CNA3. (Cross Reference F610 and F730) Findings include: Review of a facility polity titled Abuse, Neglect, Mistreatment dated 01/26/24 indicated .The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. 1. Review of a facility document for R16 titled Face Sheet provided by the facility indicated the resident was admitted to the facility on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-19 · 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, record review, and policy review, the facility failed to ensure a Certified Nurse Aide (CNA) 1 reported allegations of physical abuse by Licensed Practical Nurse (LPN) 3 against Resident (R) 93 immediately to the Administrator for 1 out of a sample of 22 residents reviewed for abuse. This failure increased the risk of other vulnerable residents for further physical abuse. Findings include: Review of a facility polity titled Abuse, Neglect, Mistreatment dated 01/26/24 indicated .It is the policy of this facility that all allegations of abuse, neglect, exploitation, mistreatment .are reported per Federal and State Law.The facility will ensure that all alleged violations as noted will be reported immediately, but no later than two hours after the allegation is made. Review of a facility document for R93 titled Face Sheet provided by the facility indicated the resident was admitted to the facility on [DATE] with a diagnosis of dementia. Review of a facility document for R93 titled quarterly…
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 · D2024-09-19 · 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 interviews and record reviews, the facility failed to ensure that allegations of abuse were thoroughly investigated for two residents (Resident (R)16 and R43) out of a sample of 22 residents reviewed for abuse. This lack of investigation had the potential to lead to continued episodes of physical and verbal abuse. Findings include: Review of a facility polity titled Abuse, Neglect, Mistreatment dated 01/26/24 indicated . To comply with the eight-step approach to abuse and neglect detection and prevention. The abuse policy will be reviewed on an annual basis and will be integrated into the Facility Assurance and Performance Improvement program. The eight components are composed of screening, training, prevention, identification, investigation, protection, reporting and response . designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed . 1. Review of a facility document for R16 titled Face Sheet provided by the facility indicated…
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 12 citations
- Potential for harm · D2024-09-19 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to notify the resident and resident's representative (RR) of a transfer or discharge in writing for one of one resident (Resident (R) 6) reviewed for hospitalization. This created a potential for the resident or their resident representative to have incomplete information, misunderstand the reason, and process for transfer or discharge, and the discharge appeal process. Findings include: Review of a facility policy titled Involuntary Transfer/Discharges 01/26/24, indicated .When discharging to another facility or continuum of care documentation in the resident's medical record must include.The facility will notify the residents and the resident's representative(s) of the transfer or discharge in writing and in a language and manner they understand. The Facility will also send a notice to the Office of the State Long Term Care Ombudsman.The state's department of protection and advocacy for the mentally ill or those with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-19 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one of one Resident (R) (R34's) clinical records out of a sample of 22 residents contained evidence the resident and/or her representative participated in the development or revision of her care plan. Findings include: Review of a facility document for R34 titled Face Sheet provided by the facility indicated the resident was admitted to the facility on [DATE]. Review of a facility document referred to as a Nursing Progress Notes provided by the facility dated 03/19/24 revealed the clinical record contained evidence R34 participated in the development/revision of her Care Plan. Review of a facility document untitled referred to a care plan invite, provided by the facility dated 05/23/24 indicated R34 was invited to participate in her care conference which was scheduled on 06/21/24. Review of R34's record failed to contain evidence the resident and/or her representative participated in her care conference scheduled on 06/21/24. Review of a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent a urinary tract infection (UTI) for 3 of 5 Residents (R90, R243, R89) reviewed for catheters as catheter bags were observed to be uncovered and resting/touching on the floor. Findings include: Review of the facility's Infection Prevention and Control Program, dated 01/26/24, revealed that the . primary mission is to establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent, treat, and control the development and transmission of communicable diseases and infection . 1. Review of R90's Face Sheet, undated and located in the resident hard chart, revealed R90 was admitted to the facility on [DATE] with diagnoses that included UTI, chronic kidney disease, and hypertension. According to the admission Minimum Data Set Assessment (MDS), with an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-19 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview, personnel file review, and policy review, the facility failed to ensure 1 of 2 Certified Nurse Assistant (CNA) (CNA2) reviewed was provided an annual performance review. This failure had the potential for decreased quality of life or quality of care for the residents. Findings include: Review of the personnel file of CNA2 revealed a copy of a document titled Performance Review and was date stamped 01/10/23. There was no current performance reviews contained in CNA2's employee record. During an interview on 09/18/24 at 3:28 PM, the Human Resource Director (HRD) stated the last performance review in CNA2's employee record was completed on 01/10/23. The HRD stated there were no current policies available for annual performance reviews of the nursing home staff. During an interview on 09/19/24 at 10:33 AM, the Interim Director of Nursing (DON) stated the county currently requires bi-annual employee performance reviews and prior to this current change it was the expectation for the facility to conduct performance reviews on an annual basis.
- Potential for harm · D2024-09-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 ensure the medication regimen was free from unnecessary medications for one (Resident (R) 43) of five residents reviewed for unnecessary medications out of a total sample of 24. The facility failed to ensure staff did not administer as needed (PRN) lorazepam (Ativan, a psychotropic anxiolytic medication) to R43 without indication for use and failed to ensure the PRN lorazepam was not prescribed beyond 14 days without documented rationale. Findings include: Review of the facility's policy titled, Psychotropic Medication Policy and Procedure, last updated 01/26/24, revealed, . Psychotropics medication may be prescribed on a PRN basis in certain situations . When a PRN psychotropics medication is ordered, the medical record will include: indication/clinical need for medication, dose and frequency for use, non-pharmacological interventions to be identified, tried, documented before administering the medication. Review of R43's quarterly Minimum Data Set…
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 · D2024-09-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medical records were complete and accurate for 1 resident (R), R89, of 22 residents sampled. The facility failed to ensure R89 had orders for an indwelling urinary catheter. This had the potential to cause R89's care needs to go unmet. Findings include: Review of R89's electronic medical record (EMR) revealed R89 was readmitted to the facility on [DATE] following a hospitalization with diagnoses that included urinary retention. Review of R89's hospital records, provided by the facility, revealed R89 had a failed voiding trial, and an indwelling urinary catheter was inserted while the resident was in the hospital. Review of R89's Physician Orders, located under the Physician Orders tab of the EMR, revealed an order to measure R89's urinary output three times daily. There was no order for a urinary catheter. Review of R89's Care Plan, dated 09/12/24 and provided by the facility, revealed a problem related to R89's need for a 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.
- Potential for harm · Dcited before2024-09-19 · 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, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one of five residents reviewed for flu/pneumonia vaccinations (Resident (R) 71) and/or their representatives, the opportunity for the residents to be vaccinated with Pneumococcal 20-valent Conjugate Vaccine PCV 20 or Pneumococcal polysaccharide vaccine 23 (PPSV23), in accordance with nationally recognized standards out of a total sample of 22 residents. Findings include: Review of the CDC website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, effective 01/28/22, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older . For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV [Pneumococcal Conjugate Vaccine] 15 or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV 23 [Pneumococcal polysaccharide vaccine] 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.
- Potential for harm · F2023-07-13 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 ensure it maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections. The facility does not have a water management plan that identifies all areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This had the potential to affect all 89 residents (R) in the facility. The facility's water management plan did not identify/assess through text and flow diagrams areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This is evidenced by: The facility policy titled, Legionella Plan, undated, indicates, in part: . The following references are incorporated in the Disaster Preparedness Plan and indicate actions that will be taken in the event of Legionella Disease detection . The chlorine dioxide generator mitigates the development of Legionella disease in the water system. A sample of water is taken 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 · D2023-07-13 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that a Discharge Summary, with a recapitulation of the resident's stay includes, but is not limited to: diagnosis, course of illness/treatment or therapy, pertinent lab, radiology, and consultant results was developed for 1 of 1 sampled residents (R94) reviewed for discharge summary/recapitulation. R94 did not have recapitulation of stay or a discharge care plan prior to being discharged from the facility. Findings include The facility's policy, titled Discharge Planning states the following *The interdisciplinary team shall prepare a comprehensive discharge plan with the resident and resident representative to assist the resident to reach their discharge goal. *A discharge summary will be completed upon discharge to include: a) A recapitulation of the residents stay in the facility (diagnosis, course of illness, treatment, therapy, lab, radiology, and consultation reports.) b) A final summary of the resident status. R94 was admitted to 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 · D2023-07-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did ensure residents unable to carry out Activities of Daily Living (ADLs) receive the necessary services to maintain good grooming by developing and implementing interventions in accordance with the residents' assessed needs, goals for cares, preferences, and recognized standards of practice that address identified limitations in residents' ability to perform ADLs for 1 (R20) of 21 residents reviewed for ADL care. - The facility failed to implement a care plan intervention to establish R20's grooming preferences. This is evidenced by: On 7/12/23, at 10:08 AM, Surveyor requested a facility policy for grooming to include nailcare and shaving from Nursing Home Administrator A (NHA). NHA A indicated that the facility does not have a grooming policy. R20 was admitted to the facility on [DATE], has diagnoses that include Type 2 diabetes mellitus with diabetic neuropathy (unspecified). R20's Certified Nursing Assistant (CNA) [NAME], printed on 7/13/23, 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.
- Potential for harm · D2023-07-13 · 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 ensure residents received care consistent with professional standards of practice to promote healing of pressure ulcers/injuries (PI) for 1 (R20) of 2 residents reviewed for PI's. -The facility failed to measure and document R20's wounds for 19 days from 6/21/23 to 7/10/23. -The facility failed to implement a care plan intervention to redistribute pressure to R20's left and right buttock pressure ulcers while in wheelchair. This is evidenced by: The Facility policy, entitled Skin Care and Pressure Injury Management, dated 5/21/2015, states: Nurses will conduct a weekly skin assessment to identify changes . if wound is present, assess after cleansing for: . size. R20 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus with diabetic neuropathy (unspecified), end stage renal disease, and unspecified atrial fibrillation. R20's admission Minimum Data Set (MDS) with a completion date of 6/19/23 indicates…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-13 · 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
Based on interview and record review, the facility must develop policies and procedures to ensure that residents and/or resident responsible party receives education regarding the benefits and potential side effects of the immunization prior to offering the immunization and documentation is noted in the medical record on whether the resident received or declined the immunization, this affected 2 of 5 residents (R14 and R19) reviewed for immunizations of 22 sampled residents. R14 did not have pneumococcal immunization offered and no documentation. R19 did not have pneumococcal immunization offered and no documentation. This is evidenced by: The facility's Pneumococcal Vaccine Policy and Procedure with a revision date of 2/27/23, states, in part: I. Purpose: To reduce morbidity and mortality from pneumococcal disease by vaccinating all adults who meet the criteria established by the Centers for Disease Control (CDC) and Prevention's Advisory Committee on Immunization Practices . III. Procedure: Vaccines help prevent pneumococcal disease, which is any type of illness caused by…
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
$42,560 in federal fines across 1 penalty.
- $42,560 — penalty dated 2025-06-18
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| COUNTY OF ROCK COUNTY CLERK | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/31/1973 |
| COLVIN, TONYA | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | — | since 12/20/2021 |
CMS files one row per role, so the 3 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 525390. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-29, 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.