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Dove Healthcare - Lodi

700 Clark St, Lodi, WI 53555 · For profit - Corporation · 50 certified beds · (608) 592-3241 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0610) — most recent Mar 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$14,433 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, 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 (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,433 in federal fines (most recent 2024-08-26)
  • nursing-staff turnover (62%) runs well above the national median (45%)
  • about 20% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Urgent care / clinic
160 Valley Dr · (608) 592-3296 · Call to confirm hours
Pharmacy
801 N Main St · (608) 592-0662 · Call to confirm hours
Grocery
805 N Main St · (608) 592-7570 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.6%16.1%15.4%better
Long-stay residents who lose too much weight1.7%5.1%5.4%better
Long-stay residents with a catheter left in their bladder0.0%2.1%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.2%2.7%2.0%better
Long-stay residents with depressive symptoms14.2%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 injury2.9%3.3%3.3%better
Long-stay residents whose ability to walk worsened11.8%18.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication9.4%16.9%18.9%better
Long-stay residents given the seasonal flu vaccine98.0%95.0%95.3%typical
Long-stay residents with pressure ulcers4.4%5.0%4.7%typical
Long-stay residents with worsening bladder/bowel control15.3%24.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table23.4%15.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine85.3%82.2%79.4%typical
Short-stay residents rehospitalized after admission16.6%23.1%22.6%better
Short-stay residents with an outpatient ER visit15.5%15.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.561.661.67worse
Long-stay outpatient ER visits per 1,000 resident days3.752.291.80worse

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.

43.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 52 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.3%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
38.5%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 38.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 26 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 SNF43.3%CMS range 32.4–53.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.7–13.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge38.5%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 discharge30.8%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 discharge23.1%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 identified100.0%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 stay2.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 4.0–11.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.801.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.62
RN hours/ resident / day
0.67
LPN hours/ resident / day
2.97
Aide hours/ resident / day
4.26
Total nurse hours/ resident / day
0.38
RN hoursweekends
62.1%
Total nursing turnover
14.3%
RN turnover

How full it usually is: this home is certified for 50 beds and averages 47.3 residents a day — about 95% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.26 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.97 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 3.74 hrs/resident/day on weekends vs 4.48 on weekdays — 17% thinner on weekends. RN hours go from 0.72 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above 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

5
deficiencies at the latest standard inspection (2026-02-18)
1
at the previous standard inspection (2024-09-27)

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.

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

  • Immediate jeopardy · Jcited before2024-08-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 each resident receives cares, consistent with professional standards of practice to prevent pressure injuries (PIs) for 2 of 3 residents (R) sampled out of a total sample of 9 (R2 and R8). R8 was admitted on [DATE], without a pressure injury or catheter. R8 was hospitalized on [DATE], returning on [DATE] with a foley catheter in place. The facility did not develop a care plan addressing the catheter until [DATE], after erosion to the penis was identified.The facility failed to ensure interventions to prevent medically related pressure injuries (PI) were implemented correctly to prevent PI development, failed to complete weekly measurements and assessments, and failed to get orders for treatments. R8 subsequently developed a full thickness wound that extended from the tip of the penis where the catheter is placed, through the meatus, and down to the shaft. These failures created a finding of immediate Jeopardy (IJ) which began 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-02-18 · 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 prepared, stored, and distributed. This has the potential to affect all 46 residents who reside in the facility.Surveyor observed kitchen staff directly touching food with dirty gloves.Surveyor observed kitchen staff not properly disinfecting thermometer while taking the temperature of food.Evidenced by:The facility policy, Food Safety Requirements, dated 6/2025, states, in part;.7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects.b. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas.The facility policy, Record of Food Temperatures, dated 3/2024, states, in part;.14. Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy.Example 1On 2/16/26 at 11:41AM, Surveyor observed [NAME] K wash his hands and put on gloves. Surveyor observed [NAME] K touch his neck, pants,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 each resident receives care, consistent with professional standards of practice (SOP), and each resident with pressure injuries (PI) receives necessary treatment and services, consistent with professional SOP, to promote healing, and prevent infection for 1 of 3 residents (R1) reviewed for PI out of a sample of 16 residents.R1's PIs were not cleaned properly during wound care and R1's PI care was not completed per physician orders.This is evidenced by:The facility's policy Wound Treatment Management, dated 2/26, includes: Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. Reference: European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance.The facility's policy Pressure Injury Prevention and Management, dated 2/26,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-18 · tag F0699 — isolated
    Provide 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 interview and record review, the facility did not ensure trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 residents (R3) reviewed for trauma informed care out of a sample of 16 residents. R3 has a diagnosis of PTSD (Post Traumatic Stress Disorder) and does not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions.This is evidenced by:The facility's policy Trauma Informed Care, dated 12/24, includes:Purpose: To provide guidance to staff regarding provision of care and services to residents who have experienced trauma. Policy: It is the policy of [Facility] to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-18 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, receives appropriate treatment and services to correct the assessed problem or attain the highest practical mental and psychosocial well-being for 1 of 1 residents (R3) reviewed out of 16 sampled residents.R3 has a diagnosis of obsessive compulsive disorder (OCD) her comprehensive care plan does not include known triggers, resident specific goals, or personalized interventions related to her OCD.This is evidenced by:The facility's policy Trauma Informed Care, dated 12/24, includes: Purpose: To provide guidance to staff regarding provision of care and services to residents who have experienced trauma. Policy: It is the policy of [Facility] to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-18 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    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

    Based on observation, interview, and record review, the facility did not ensure food was served in a manner that conserved palatability and temperature for 1 resident (R30) and one test tray.R30 voiced concern regarding hot food being served cold. Surveyor's test tray temped cold.Evidenced by:The facility policy, Record of Food Temperatures, dated 3/24, states, in part;.2. Hot foods will be held at 135 degrees Fahrenheit or greater.11. No food will be served that does not meet the food code standard temperatures.On 2/17/26 at 9:58 AM, R30 voiced concerns regarding food temperatures and palatability. On 2/18/26 at 12:31PM, Surveyor followed back up with R30. R30 indicated she eats in her bedroom, and she is down the hallway that gets served room trays first. R30 indicated that her hot food is often served cold and she is one of the first served so the rest of the trays must be cold as well. R30 indicated she has heard other residents voice concerns regarding the food temperatures as well.On 2/18/26 at 12:21 PM, Surveyor received test tray. The meat/peppers/cheese sandwich temperature…

    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 · D2025-06-13 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure 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 record review, interview, and facility document review, the facility failed to prevent significant medication errors for two out of a total of five residents reviewed for medication administration (R2, and R3) out of a total sample of 13 residents. This failure had the potential for R2 and R3 to experience adverse reactions from receiving a wrong medication or wrong dosage of medication that was not prescribed for R2 and R3. Findings include: Review of the facility's policy Medication Administration dated 01/01/25 indicated, .Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation [sic] .Compare medication source (bubble pack, vial, etc.) with the MAR [Medication Administration Record] to [NAME] resident name, medication name, form, route, and time . 1.Review of R1's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R1 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-09-27 · 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, record review, and facility policy review, the facility staff failed to document monitoring of the temperatures for the freezers and refrigerators located in the kitchen, document monitoring of the temperature and sanitizing solution for the dish machine, date numerous spices with open dates, and maintain the tile kitchen flooring. This failure had the potential to negatively impact all 47 residents currently residing in the facility who ate food from the kitchen. Findings include: Review of the facility's policy titled, Monitoring of Cooler/Freezer Temperature, dated 06/15/23, revealed, Policy: It is the policy of this facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety . Policy Explanation and Compliance Guidelines:1 . a. Temperatures will be checked and logged at least twice per day by designated personnel . Review of the facility's policy titled, Dishwasher Temperature, dated 06/15/23, revealed, Policy: It is the policy of this facility to ensure dishes and utensils are cleaned under…

    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 · E2024-08-26 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility did not ensure each resident has the right to privacy and confidentiality for 7 of 9 residents (R) reviewed. (R3, R4, R5, R6, R7, R8, and R9) During the survey, a camera was observed to be used for surveillance in the facility dining room. The dining room is used throughout the day for meals and visits. Evidenced by: On 8/14/24 at 11:00 AM, Surveyor observed a camera in the dining room, just inside the doorway from the hallway. Surveyor noted the dining room is used throughout the day by residents for meals and visits. This includes R3, R4, R5, R6, R7, R8, and R9. Surveyor noted there was no signage or posted notification to any resident, family, or staff who may use the dining room that the room was under surveillance by a camera. On 8/14/24 at 12:00 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if there were any cameras in the dining room NHA A stated not to her knowledge. NHA A opened the camera feed on her computer. NHA A and Surveyor observed a video of the dining room with residents eating the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R1) reviewed for fall concerns out of a total sample of 9 residents. R1 had a fall on [DATE] and the facility did not ensure that R1's fall was investigated or that care planned fall interventions were placed on R1's plan of care and implemented. This is evidenced by: The facility's policy titled, Fall Prevention Program, last reviewed [DATE], states, in part: . Purpose: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-19 · 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 record review and interviews, during an investigation of [NAME] ncident of verbal abuse of R3, the facility did not conduct interviews for potential abuse for other residents, and did not monitor R3 for potential negative psychosocial outcomes following incident. Findings include: Facility policy entitled Abuse, Neglect and Exploitation, implemented on 02/03/2024, under section V. Investigation of alleged abuse, neglect and exploitation, states in part 5, Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. Under section VI. Protection of Resident, states in part, Providing emotional support and counseling to the resident during and after the investigation as needed. The facility filed a self-report regarding verbal abuse that occurred towards R3 on 12/22/23. On that morning R3 expressed the coffee tasted like water. Dietary Manger (DM) D swore at R3 and told R3 to stop his f------ bi------. The facility did immediately…

    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
Show the remaining 11 citations
  • Potential for harm · Fcited before2023-08-29 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that food was stored, distributed, and served in accordance with professional standards for food service safety. This has the potential to affect all 40 residents residing at the facility. Surveyor observed: -An unknown matter in dishwasher area. -Machine washing and sanitation. The facility did not monitor dishwasher readings consistently. -Two instances of cross contamination. -Two instances of improper food storage. -Three instances of improper containment of garbage and refuse. The facility policy, entitled Sanitation Inspection, dated 6/15/23, states: It is the policy of this facility, as a part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations . 5. Inspections will be conducted but not limited to the following areas: a. dry storage b. freezer c. refrigerator d. dish room e. pot wash f. main production…

    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 · F2023-08-29 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not maintain a Quality Assessment and Assurance Committee consisting of at a minimum, the Director of Nursing Services, the Medical Director, or his/her designee, at least three other members of the facility's staff at least one of whom must be the administrator, owner, a board member or other individual in a leadership role, and the Infection Preventionist, which met at least quarterly. This has the potential to affect all 40 Residents residing within the facility. QAPI meetings did not consist of the required attendees/members for the month of January 2023, April 2023, and July 2023. This is evidenced by: The facility policy, entitled Quality Assurance and Performance Improvement (QAPI), dated 7/01/22, states, in part: . Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides . Policy Explanation and Compliance…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-29 · tag F0657 — failed to keep the care plan current — pattern
    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 conduct care conferences which included the participation of the Interdisciplinary Team (IDT) and the resident or resident's representative after completion of each comprehensive assessment (at least quarterly) or include an explanation in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan for 10 of 12 residents (R) sampled (R33, R38, R29, R2, R7, R39, R28, R23, R30, and R8). R33, R38, R29, R2, R7, R39, R28, R23, R30, and R8 did not have quarterly care conferences completed. This is evidenced by: The facility policy, entitled Care Planning-Resident Participation, dated 8/02/22, states, in part: . Policy: This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care). Policy Explanation and Compliance Guidelines: 1. The facility will inform 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide a safe environment and adequate supervision to prevent accidents. This had the potential to affect 1 out of 12 sampled residents (R40) and 4 out of 4 supplemental residents (R22, R19, R37, R27). Surveyor observed the stove/oven unit in the facility's activity room to be connected to a power source and was able to turn on the burners and the oven. Surveyor also observed R40, R22, R19, R37, and R27 in the activity room unsupervised. Evidenced by: Facility policy entitled Activity Department Stove/Oven, undated, includes the following, in part: date implemented: (blank), date reviewed/revised: (blank), reviewed/revised by: (blank) . Policy: A safe and healthful work environment will be provided for all employees, residents, and visitors. Pursuant to this end, the activity stove/oven will be properly cleaned and maintained to support the functioning of the activity stove/oven. Policy explanation and Compliance Guide: the activity…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-29 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not immediately consult with the Resident's Physician when there was need to alter treatment for 2 of 15 residents (R42, R23). R42 experienced a change in condition and the facility did not notify NP U (Nurse Practitioner) of R42's change in condition so that NP U could direct the care of R42. R23 had an abnormal x-ray and staff did not notify the medical doctor timely. Evidenced by: The facility policy, entitled Notification of Changes, date implemented 7/6/23, includes in part: The facility must inform the resident, consult with the resident's physician, and/or notify the resident's family member or legal representative when there is a change requiring such notification: Circumstances requiring notification include: Circumstances that require a need to alter treatment . Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status. This may include life threatening…

    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 · D2023-08-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 1 of 12 residents (R38) out of a total sample of 15. Surveyor observed R38's room to be unclean and odorous. This is evidenced by: The facility policy, entitled Routine Cleaning and Disinfection, dated 6/1/23, states, in part: . POLICY: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible . Policy Explanation and Compliance Guidelines: 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms . 4. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-29 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not follow their grievance process for 1 of 15 Residents (R38). VTR G (R38's visitor) and R38 voiced concern to staff regarding odor in R38's room and facility did not follow the grievance process. This is evidenced by: The facility policy, entitled Resident and Family Grievances, dated 7/01/23, states, in part: . Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal . Policy Explanation and Compliance Guidelines: . 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary considering specific…

    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 · D2023-08-29 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop 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 that all staff had background checks completed every four years which is part of preventing abuse. This affected 2 of 9 staff reviewed. CNA H (Certified Nursing Assistant) did not have a background check completed every four years. CNA/MT I (Med Tech) did not have a background check completed every four years. This is evidenced by: The facility's Policy and Procedure entitled Background Investigations dated 7/2023 does not speak to completing background checks every four years, only speaks to upon hire. Example 1 CNA H's hire date was 2/21/19. Her last completed background check was completed on 2/21/19. CNA H should have had a background check completed by 2/21/23. Example 2 CNA/MT I's hire date was 2/15/19. Her last background check was completed on 2/15/19. CNA/MT I should have had a background check completed by 2/15/23. On 8/29/23 at 3:36 PM, Surveyor interviewed BOM J (Business Office Manager). Surveyor asked BOM J when background checks are supposed to be completed, BOM J said prior to hire. Surveyor asked BOM…

    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 · D2023-08-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility did not ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain or enhance the resident's physical abilities for 1 (R30) of 12 residents reviewed for activities of daily living (ADLs) out of a total sample of 15 residents. R30 depends on staff to meet her needs in toileting, transfer, and bed mobility. R30 voiced concerns of stiffness, weakness, incontinence, and pain due to staff not allowing her to use the standing lift and only using the Hoyer lift with her during transfers. Surveyor observed staff use the Hoyer lift with R30 and not offer her to use the standing lift, a bedpan, or to sit on the toilet with morning cares. Evidenced by: R30 admitted to the facility 7/1/20 and has the following diagnoses: cerebral palsy, muscle wasting and atrophy, cancer of the right breast, and pain in right knee. R30's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/28/23, indicates R30 is cognitively intact with a Brief Interview for Mental…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure assessments were completed following a change of condition for 1 of 12 of 15 total residents reviewed for change of condition. The facility did not monitor, assess, or document R24's bowel sounds during an exacerbation of R24's chronic bowel conditions including ileus (when intestine stops making wave-like movements) and neurogenic bowel (loss of normal bowel function due to a nerve problem). This is evidenced by: On 8/29/23 at 12:01 PM, Surveyor requested a bowel policy from the facility. Surveyor reviewed the facility policy, entitled Bowel and Bladder Incontinence Policy dated 9/2/22, the facility policy, entitled Notification of Changes dated 7/6/23, and the facility protocol, entitled Bowel Protocol not dated. (It is important to note that the facilities Bowel and Bladder Incontinence Policy, Notification of Changes, and Bowel Protocol do not include procedures for a licensed nurse at the facility to monitor, assess, or document bowel sounds…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-29 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 observation, interview, and record review, the facility failed to monitor behaviors and symptoms of mental illness for 1 of 5 sampled residents out of a total sample of 15 (R40). R40 was diagnosed with dementia and is prescribed and administered anti-psychotic medications without targeted behavioral monitoring or use of non-pharmaceutical interventions to support or understand them or to prevent, relieve, or accommodate distress. This is evidenced by: Facility policy, entitled Psychotropic Medication Prescribing Guidelines, implemented 8/22, includes, in part: Antipsychotics Require clear documentation of diagnosis and indication for use, multiple attempts at care-planned non-drug interventions ., and ongoing evaluation of these approaches. Diagnoses alone do not warrant use. Indication may be warranted if: - Behavioral symptoms present danger to self or others, - Expressions or indications of distress that are significant to the resident, - If not clinically contraindicated, non-pharmacological…

    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

“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

$14,433 in federal fines across 1 penalty.

  • $14,433 — penalty dated 2024-08-26

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to DOVE HEALTHCARE — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.2-0.2 vs chain
Health inspection 3 of 53.1-0.1 vs chain
Staffing 4 of 53.6+0.4 vs chain
Quality measures 3 of 53.4-0.4 vs chain
The other 10 homes this chain runs (chain average 3.2★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
WISCONSIN 3 HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/06/2018
MARKOVITS, ISAAKIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR50%since 02/15/2019
RICHLAND, ILANIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL50%since 02/15/2019

CMS files one row per role, so the 5 rows in the source record cover these 3 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.

$5.8M
Net patient revenuemost recent cost report
-1.7%
Operating marginrevenue minus expenses
$1.2M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 66%Medicare 8%Other / private 26%

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$385per resident / day
operating cost
$11,707per month
≈ monthly operating cost
$379per 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 525520. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-18, 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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