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Lancaster Health Services

1350 S Madison St, Lancaster, WI 53813 · For profit - Limited Liability company · 50 certified beds · (608) 723-4143 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0605) — cited Aug 20251 immediate-jeopardy citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0605), cited Aug 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (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 (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 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

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
500 S Madison St · (608) 723-2131 · Call to confirm hours
Pharmacy
139 W Maple St · (608) 723-4737 · Call to confirm hours
Grocery
209 E Maple St · (608) 723-0024 · Call to confirm hours
Park
Baus Park0.3 mi
250 W Nathan St · Typically dawn to dusk
Place of worship
133 W Oak St · (608) 723-4441

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5

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 fell from 3 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
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 increased17.5%16.1%15.4%worse
Long-stay residents who lose too much weight2.5%5.1%5.4%better
Long-stay residents with a catheter left in their bladder1.2%2.1%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%2.7%2.0%better
Long-stay residents with depressive symptoms10.2%5.7%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.0%3.3%3.3%worse
Long-stay residents whose ability to walk worsened20.2%18.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication15.7%16.9%18.9%better
Long-stay residents given the seasonal flu vaccine94.7%95.0%95.3%typical
Long-stay residents with pressure ulcers3.5%5.0%4.7%better
Long-stay residents with worsening bladder/bowel control23.3%24.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table23.9%15.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.8%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine75.9%82.2%79.4%typical
Long-stay hospitalizations per 1,000 resident days0.711.661.67better
Long-stay outpatient ER visits per 1,000 resident days2.972.291.80worse

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.

50.0%U.S. median 56.6%
Met the expected recovery
0.13U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.03hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 22 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 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge50.0%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 discharge59.1%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 discharge45.5%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 identified92.0%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 worsened4.0%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

0.69
RN hours/ resident / day
0.73
LPN hours/ resident / day
2.21
Aide hours/ resident / day
3.62
Total nurse hours/ resident / day
0.37
RN hoursweekends
28.0%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 50 beds and averages 42.1 residents a day — about 84% occupied, or roughly 8 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 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 3.29 hrs/resident/day on weekends vs 3.76 on weekdays — 13% thinner on weekends. RN hours go from 0.81 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 28% is below the national median of 45%. 1 administrator has left in the past year.

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

7
deficiencies at the latest standard inspection (2025-08-19)
3
at the previous standard inspection (2024-07-24)

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

Inspection deficiencies

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

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.

18 citations, most serious first. The 11 most serious are shown; the remaining 7 are one tap away and print in full.

  • Immediate jeopardy · J2025-08-19 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure that 1 (R8) of 5 residents drug regimen was free from unnecessary drugs. R8 was prescribed Risperidone for verbal and physical aggression. The facility failed to adequately monitor R8's response to Risperidone and failed to recognize adverse consequences of Risperidone therapy including lethargy, decreased Activities of Daily Living (ADL) function and decreased oral intake. The facility failed to adjust R8's Risperidone when R8 presented with adverse consequences. R8 was administered Risperidone (Antipsychotic) daily starting on 6/22/25 following two days of intermittent verbal and physical aggression. Following initiation of Risperidone, R8 presented with lethargy, decreases in activity participation, ADL abilities and oral intake. The facility continued the Risperidone without evidence of monitoring for adverse consequences or side effects related to the initiation of the antipsychotic. The Risperidone was not reduced in attempts 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-08-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 39 of 39 residents.Surveyor observed food to have been removed from the original packaging and not dated with an expiration date, an open date, or a use by date. Evidenced by: Facility policy, entitled Food Storage, date revised 8/16/2022, states in part: .13. Frozen Foods: .c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. Example - Undated food removed from original packaging On 8/4/25 at 9:35 AM, during the initial tour of the kitchen, Surveyor observed in the freezer the following: an opened package of mixed vegetables, out of original cardboard box, without a use by or expiration date; an opened package of diced carrots, out of original cardboard box, without a use by or expiration date; an opened package of peas, out of original cardboard box, without a use 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-19 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 2 of 16 sampled residents (R4 and R22) and 13 residents who eat in the main dining room. R4 voiced concerns with his cold food not being cold enough.R22 voiced concerns with vegetables being mushy.Surveyor conducted 1 test tray for the main dining room which was not palatable. Evidenced by: Facility policy, entitled Food Storage, last revised 8/16/2022, includes, in part: . 12. Refrigerated food storage: b. TCS (time/temperature control for safety) foods must be maintained at or below 41 degrees Fahrenheit unless otherwise specified by the law. Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41 degrees Fahrenheit. Example 1 R4 admitted to the facility on [DATE]. R4's most recent Minimum Data Set (MDS), with a target date of 5/28/25, indicates 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 · D2025-08-19 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 the resident's right to request, refuse, and/or discontinue treatment and to formulate an advanced directive for 2 of 12 residents (R2 and R32) reviewed. R2 and R32's charts did not contain current copies of their advanced directive and/or did not contain evidence of advanced care planning, other than code status, for a time when they are not able to make their own healthcare decisions. Evidenced by:On 8/7/25 at 11:08 AM, ADON D (Assistant Director of Nursing) informed surveyor that they did not have an advanced directive policy.The facility admission Agreement, indicates, in part: Advanced Directives Policy and Record: Policy: It is the Center's policy to recognize and implement the resident's rights under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment, and the right to formulate Advance Directives.Example 1R2 was admitted to the facility on [DATE].On 8/5/25 at 10:53 AM, During 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 · D2025-08-19 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 interview and record review, the facility did not ensure care plans were reviewed and/or revised for 2 of 16 (R8 and R9) residents reviewed. Facility staff did not revise R8's care plan to address his hospice status and did not have the hospice agency care plan available for facility staff. R9's comprehensive care plan does not include a focus, goal or interventions for depression. Evidenced by: The facility policy titled, “Comprehensive Care Plan,” indicates, in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment…Policy Explanation and Compliance Guidelines: …5. The comprehensive care plan will be reviewed and revised as appropriate by the interdisciplinary team after each comprehensive and quarterly 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-19 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors in 29 opportunities that affected 2 out of 7 supplemental residents (R23 & R25) included in the medication pass task, which resulted in an error rate of 6.9%. R23 received insulin from an insulin pen that had not been primed prior to use. R25 did not receive the correct dose of Vitamin D3. Evidenced by: The facility policy entitled, Medication Administration General Guidelines, dated 1/2025, states, in part: .Policy: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices. Procedures:. Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. 9. Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart. b. When dose is prepared. c. Before dose 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-19 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement 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 failed to ensure they followed standards of practice for an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 (R21) of 8 supplemental residents reviewed for antibiotic stewardship. R21 was diagnosed with a urinary tract infection. The physician ordered the antibiotic Bactrim DS (trimethoprim/sulfamethoxazole). The urine culture and susceptibility indicated the bacteria causing R21's urinary tract infection was resistant to Bactrim DS. After this result, R21's ordered antibiotic was not changed. Evidenced by: The facility's Antibiotic Stewardship Program policy, dated 11/18/22, states, in part: Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.4. The…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-19 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately for 2 of 3 residents reviewed for abuse (R1 and R2). An allegation of abuse was made by CNA G (Certified Nursing Assistant) regarding CNA F, five days after the alleged incident occurred. CNA C had knowledge of an allegation of abuse involving CNA F and R2, and this was not reported. Laundry/Hskp D (Laundry/Housekeeper) witnessed and had knowledge of a potential abuse situation with CNA F and did not report this to anyone. Findings include The facility's policy, titled Abuse Prevention Program states, in part: *Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-19 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for 2 of 3 residents (R1 and R2). An allegation of abuse was made by CNA G (Certified Nursing Assistant) regarding CNA F five days after the alleged incident occurred with R1. The facility did not interview all staff, who had knowledge of other allegations. CNA C and CNA E had knowledge of an allegation of abuse involving CNA F and R2, and this was not investigated. Housekeeper D witnessed and had knowledge of a potential abuse situation with CNA F, and this was not investigated. Findings include: The facility's policy, titled Abuse Prevention Program states, in part: *Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. *Staff are to report suspected violations 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-27 · 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 interview and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 3 residents (R1) reviewed for pain. The facility failed to re-evaluate the effectiveness of R1's pain medication within one hour of being administered, failed to offer non-pharmacological interventions related to pain management, and failed to consult with R1's Medical Doctor when her pain rating was consistently above her goal rate of 2 out of 10. This is evidenced by: Facility did not provide a policy related to pain rating and pain assessment. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Type 2 diabetes, pain in right knee, pain in left knee, and other chronic pain. On 8/27/24 at 10:08 AM, Surveyor interviewed RR E (Resident Representative). RR E reported to Surveyor that R1 was not being given pain medications overnight. Additionally, RR E states that R1 has…

    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 · F2024-07-24 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to submit accurate data to Centers for Medicare and Medicaid Services (CMS) mandatory Payroll Based Journal (PBJ) for Quarter 4 2023, Quarter 1 2024, and Quarter 2 2024. This had the potential to affect all 38 residents. Findings: On 07/22/24 at 1:21 PM, Surveyor interviewed Business Office Manager (BOM) G about the low weekend staffing data and no Registered Nurse (RN) that was triggered in the PBJ report. Surveyor asked for the information that was submitted. On 07/23/24 at 9:46 AM, Surveyor interviewed BOM G and asked for the information submitted for the PBJ. BOM G replied, I thought that you already had that information, so I wasn't sure if I needed to print that out or not. Surveyor replied, I need to see what you submitted in order to know why it was triggered. BOM G replied, Yes, I will do that. On 07/23/24 at 10:23 AM, BOM G provided Surveyor with PBJ submitter Final File Validation Report to review. On 07/23/24 at 2:45 PM, Surveyor requested…

    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 · Past Non-Compliance
Show the remaining 7 citations
  • Potential for harm · D2024-07-24 · 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 interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. This occurred for 1 of 3 sampled residents (R6) who is prescribed a prophylactic antibiotic without adequate indications for its use. R6 returned from the hospital with an order for a prophylactic antibiotic (Cephalexin). No diagnosis was listed for this order. No stop date was listed for this order. This is evidenced by Facility policy and procedure entitled Antibiotic Stewardship Program, dated 11/18/22, states in part: Prescriptions for antibiotics shall specify the dose, duration, and indication for use. R6 was admitted to the facility with diagnoses that include chronic respiratory failure, respiratory failure with hypoxia, hypertension, congestive heart failure, chronic kidney disease, and Alzheimer disease. R6's Quarterly Minimum Data Set (MDS) assessment, dated 5/3/24, indicated that R6 had a Brief interview for Mental Status (BIMS) of 7 indicating severe cognitive impairment.…

    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 before2024-07-24 · 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 random observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections. Staff did not perform hand hygiene when warranted when providing cares for 3 of 3 residents (R24, R27, and R3). Staff did not perform sanitizing of durable medical equipment to prevent the spread of infection when warranted between 2 residents (R3 and R24). This is evidenced by: The facility policy entitled Hand Hygiene revised on 11/02/22 states in part . • All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. • Either soap and water or alcohol-based hand rub before applying and after removing personal protective equipment, including gloves, before and after handling clean or soiled linens, and after handling items potentially contaminated with blood, body fluids, secretions or excretions. The facility was unable 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 · Dcited before2024-04-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not immediately report alleged violations of abuse to the State Agency and local law enforcement for 2 of 3 reportable incidents (R8 and R9). On 3/21/24, R8 reported that he was unable to find the cash that he kept in his room. R8 indicated that there was a grand that he was unable to locate. NHA A failed to report this Suspicion of a Crime to local law enforcement and the State Agency. On 3/16/24, R9's daughter called the facility to report that R9's wedding ring was missing. NHA A failed to investigate the allegation or report this Suspicion of a Crime to local law enforcement and the State Agency. This is evidenced by: The facility's policy and procedure, Abuse, Neglect, Exploitation Policy, last revised 7/15/22, states in part, the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-04-06 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is stored and distributed in accordance with professional standards for food service safety. This has the potential to affect all 33 residents who reside in the facility. Surveyor observed DA F (Dietary Aide) during dishwashing. Surveyor observed DA F go from working with dirty dishes to clean dishes four times without washing hands in between. Evidenced by: The facility policy titled, Cleaning Dishes Dish Machine, with a reviewed date of 7/13/22, includes, in part: Policy Explanation and Compliance Guidelines .2. The person loading dirty dishes will not handle the clean dishes unless they change into a clean apron and wash hands thoroughly before moving from dirty to clean dishes .10. Inspect for cleanliness and dryness and put dishes away if clean (be sure clean hands or gloves are used) On 4/5/23 at 9:35 AM, Surveyor observed DA F rinsing and placing dirty dishes in the dishwasher. Surveyor observed DA F then start putting clean dishes away. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-04-06 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, this has the potential to affect all 33 residents (R) in the facility. The facility's staff infection control line list contained missing and/or incorrect information. Dietary Aide H returned to work sooner than current infection control standards of practice recommend. The facility's monthly infection control rates were not calculated according to current standards of practice and rates were not segregated for specific infection types. Staff administered R86's eye drops without gloves or proper hand hygiene. Surveyor observed DA F (Dietary Aide) touch her face mask twice and then touch the top of a drink pitcher without washing her hands. This is evidenced by: The facility policy titled, Infection Surveillance, with a revised…

    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 · D2023-04-06 · 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

    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 1 of 5 residents (R9) reviewed for pneumococcal immunizations of 16 sampled residents. R9 did not have the pneumococcal immunization and no documentation in R9's record. This evidenced by: The facility policy, entitled, Pneumococcal Vaccine (Series), with a revised date of 2/20/23, states, in part: Policy: It is our policy to offer our residents and staff immunization against pneumococcal disease in accordance with current CDC (Centers for Disease Control) guidelines and recommendations. Policy Explanation and Compliance Guidelines: 1. Each resident will be assessed for pneumococcal immunization upon admission .2. Each resident will be offered a pneumococcal immunization unless it is medically…

    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
  • No harm found · C2023-04-06 · tag F0888 — widespread
    Ensure staff are vaccinated for COVID-19
    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 all staff who provide care to the residents were fully vaccinated for COVID-19. This had the potential to affect all 33 residents. Cook D, with a date of hire of 7/14/22, was not fully vaccinated for COVID-19 while working in the facility and did not have a temporary delay or exemption from receiving the COVID-19 vaccination. This is evidenced by: The facility policy, Employee COVID-19 Vaccinations, with a revised date of 10/24/22, indicates, in part: Policy: It is the policy of this facility to ensure that all eligible employees are vaccinated against COVID-19 as per applicable Federal, State and local guidelines . Compliance Guidelines: 1. The facility will ensure that all eligible employees are fully vaccinated against COVID-19, unless religious or medical exemptions are granted as per CMS (Centers for Medicare and Medicaid Services) guided time frames .4. The facility will ensure that all eligible employees (except for staff who have pending requests for, or who have been granted exemptions to the vaccination…

    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

“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 NORTH SHORE HEALTHCARE — 59 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.7-0.7 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 4 of 53.4+0.6 vs chain
Quality measures 3 of 52.5+0.5 vs chain
The other 58 homes this chain runs (chain average 2.7★, per CMS)
1 of 5Elroy Health ServicesElroy, WI 1 of 5Florence Health ServicesFlorence, WI 1 of 5Hopkins Restorative Care CenterHopkins, MN 1 of 5La Crescent Health ServicesLa Crescent, MN 1 of 5Little Chute Health ServicesLittle Chute, WI 1 of 5Minot Health And Rehab, LLCMinot, ND 1 of 5Plymouth Health ServicesPlymouth, WI 1 of 5Rochester Restorative Care CenterRochester, MN 1 of 5Sheboygan Progressive Health ServicesSheboygan, WI 1 of 5Williams Bay Health ServicesWilliams Bay, WI 1 of 5Wisconsin Rapids Health ServicesWisconsin Rapids, WI 2 of 5Birch Hill Health ServicesShawano, WI 2 of 5Colonial Health ServicesColby, WI 2 of 5Evergreen Health ServicesShawano, WI 2 of 5Green Bay Health ServicesGreen Bay, WI 2 of 5Heritage Health ServicesPort Washington, WI 2 of 5Lake Country Health ServicesOconomowoc, WI 2 of 5Maple Ridge Health ServicesMilwaukee, WI 2 of 5Menomonee Falls Health ServicesMenomonee Falls, WI 2 of 5Mineral Point Health ServicesMineral Point, WI 2 of 5Soldiers Grove Health ServicesSoldiers Grove, WI 2 of 5Stevens Point Health ServicesStevens Point, WI 2 of 5Sunrise Health ServicesMilwaukee, WI 2 of 5Three Oaks Health ServicesMarshfield, WI 2 of 5Tomahawk Health ServicesTomahawk, WI 2 of 5Whitewater Health ServicesSt Charles, MN 2 of 5Willowcrest Health ServicesSouth Milwaukee, WI 3 of 5Cedarburg Health ServicesCedarburg, WI 3 of 5Court Manor Health ServicesAshland, WI 3 of 5Hayward Health ServicesHayward, WI 3 of 5Homestead Health ServicesNew Holstein, WI 3 of 5Mercy Health ServicesMilwaukee, WI 3 of 5Morningside Health ServicesSheboygan, WI 3 of 5Oakwood Health ServicesAltoona, WI 3 of 5Randolph Health ServicesRandolph, WI 3 of 5Rib Lake Health ServicesRib Lake, WI 3 of 5River's Bend Health ServicesManitowoc, WI 3 of 5Riverview Health ServicesTomahawk, WI 3 of 5Sheboygan Health ServicesSheboygan, WI 3 of 5St Francis Health ServicesSaint Francis, WI

Showing 40 of 58; lowest-rated first.

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
NSHR OPERATIONS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/01/2019
ARROWHEAD 123 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF10%since 10/01/2019
THE LANE MORRELL BOWEN TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF10%since 10/01/2019
MILLS, DAVIDIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST18%since 10/01/2019
CIBC BANK USAOrganization5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 12/31/2024
BAUMANN, TROYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2019
HOEHN, JEFFREYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2019
CLIFTONLARSONALLEN LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/06/2025
CONTINUUM THERAPY PARTNERS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
NORTH SHORE HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/06/2025
NSH REHAB LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
WIPFLI LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2025
BELONGIA, CHRISTINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2019
GEE, DARRENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/30/2021
GREER, LAURENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/29/2023
HORSTMAN, NATALIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/21/2026
PATZER, COLLEENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/14/2023
PURTELL, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2019
SLANE, ERICIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2023
NSH 1350 SOUTH MADISON STREET LLCOrganizationADP OF THE SNFsince 12/01/2019

CMS files one row per role, so the 40 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.

10 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$3.5M
Net patient revenuemost recent cost report
-0.7%
Operating marginrevenue minus expenses
$176K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 30%Medicare 7%Other / private 63%

This home reported $176K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$287per resident / day
operating cost
$8,728per month
≈ monthly operating cost
$285per 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 525352. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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