United Pioneer Home
623 S Second St, Luck, WI 54853 · Non profit - Corporation · 50 certified beds · (715) 472-2164 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (24) — 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
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 17.6% | 16.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.6% | 5.1% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 19.0% | 2.1% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 11.7% | 2.7% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 5.2% | 5.7% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.0% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.6% | 18.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.0% | 16.9% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.0% | 5.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.7% | 24.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.3% | 15.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents rehospitalized after admission | 19.6% | 23.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 13.5% | 15.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.73 | 1.66 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.51 | 2.29 | 1.80 | better |
‡ 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.
44.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 32.1% 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 28 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 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 44.4%CMS range 32.8–56.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 5.7–17.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 32.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 35.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 7.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 90.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | 1.11 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 50 beds and averages 44.0 residents a day — about 88% occupied, or roughly 6 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 4.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.93 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.42 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 4.50 hrs/resident/day on weekends vs 5.02 on weekdays — 10% thinner on weekends. RN hours go from 1.05 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · Gcited before2025-08-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not implement new interventions and increase supervision when needed to prevent accidents for 2 of 3 residents (R) (R1, R2) reviewed.-R1 is at risk for falls and fell on [DATE], 12/30/24, 01/01/25, 01/09/25, 05/13/25, 06/06/25, 08/04/25, 08/05/25, and the facility did not place new interventions or increase supervision to prevent further fall incidents. On 08/06/25, x-ray results revealed a left humeral head fracture. On 08/08/25, additional x-rays of left knee related to complaints of pain, revealed an acute transverse non-displaced fracture of the mid portion of the left patella. The facility failure to place new interventions and increase supervision for R1 led to harm, when R1 suffered a left humeral head fracture and an acute transverse non-displaced fracture of the mid portion of the left patella. This example is cited at a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-09-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility did not ensure food was stored and prepared in a sanitary manner that prevents foodborne illness to the residents. This practice had the potential to affect all 40 residents within the facility.*Open food noted in cold storage, not labeled and dated.*Cook D did not have a hair net on mustache. Findings:Labeling open foods:The 2022 FDS Food Code documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food: Disposition .A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections.On 09/22/2025 at 8:33 AM, during initial tour of the kitchen, Dietary Director (DD) C provided Surveyor with a tour of the cold storage items.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-24 · tag F0628 — patternProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure residents/representatives were notified of the rate to reserve the resident's bed in the bed hold notice. This has the potential to affect 2 of 5 residents R9 received bed hold notices with no daily rate documented and no information on resident appeal rights. R5 received bed hold notices with no daily rate documented and no information on resident appeal rights. R3's bed hold notices did not have daily rate documented and no information on resident appeal rights. R15 received a verbal bed hold notice, but facility did not have any documentation that R15 received the daily rate or information on resident appeal rights. R16 received a bed hold notice but it did not have the daily rate documented nor information on resident appeal rights. Findings: Example 1 R9 was admitted to the facility on [DATE], with a Brief Interview of Mental Status (BIMS) score of 10/15, which indicated that R9 was cognitively intact. R9 had diagnoses of dementia, chronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-24 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility did not establish and maintain 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 affected residents (R) R29, R41, R17, R16, R21, and R15. Certified Nursing Assistant (CNA) G did not perform hand hygiene when passing water pitchers to R29, R41, R17, R16, and R21. CNA H did not perform hand hygiene when providing peri cares to R15. Maintenance F entered R16's droplet precaution room without donning PPE when cleaning R16's room. Findings include: The facility policy titled Transmission Based Precautions dated last review March 2025, in part reads: .Contact Precautions: #2. Wear gloves when entering room. Wear gown when contact with the resident or potentially contaminated surfaces in their environment will occur.Droplet Precautions: #2. In addition to contact precaution measures, a mask shall be donned when entering the room for contact within 6 feet for the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not use appropriate assist devices during transfer when needed to prevent accidents which affected resident (R) (R6).Certified Nurse Assistant (CNA) H did not use gait belt while transferring R6 from toilet to wheelchair.Findings include:Facility policy titled, Fall Protocol, dated reviewed in February 2025, states in part: .Definition: A fall refers to unintentionally coming to rest on the ground, floor, or other lower level. An episode where resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. Facility policy titled, Safe Resident Handling, dated reviewed in September 2017, states in part: .#5. Direct resident care staff will avoid manually lifting residents except for medical emergencies.#7. Suggested patient/resident handling aids: Minimal assist: The resident is ambulatory, able 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.
- Potential for harm · D2025-09-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure standards of practice were followed for providing respiratory services for 1 of 1 resident (R) reviewed for oxygen therapy (R15). Certified Nurse Assistant (CNA) H did not check portable oxygen tank before taking R15 to lounge for an activity according to facility policy. The facility did not implement new respiratory interventions after each episode of R15 found with no oxygen on. Findings include:Surveyor reviewed the facility protocol titled Oxygen Therapy, last reviewed in April 2019, states in part, .initiating oxygen: 2. Turn on the oxygen to the prescribed flow rate. 3. Place appropriate oxygen to device on the resident (i.e., mask, nasal cannula and/or nasal catheter). 5. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. 6. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. R15 was re-admitted to the facility on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-24 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility did not ensure that residents are free of significant medication errors for 1 of 12 residents (R12) reviewed for medication errors. R12 has a type 2 diabetes mellitus diagnosis. Facility staff administered short acting insulin 4 hours after Blood Glucose (BG) was taken. Facility staff did not follow standards of practice for insulin administration. Findings include:Surveyor reviewed the policy titled, Insulin Administration, dated reviewed in January 2017, which stated in part, .Insulin Pen: #2. Check blood glucose per physician order or facility protocol.On 09/23/25 at 9:34 AM, Surveyor observed Registered Nurse (RN) I administer Humalog KwikPen 33 units subcutaneous in R12's left abdomen. RN I read out loud to Surveyor that R12's BG (blood glucose) was 173 and completed at 4:12 AM earlier this morning from night shift. RN I reported to Surveyor that R12 will receive sliding scale insulin as well. Surveyor observed RN I give Humalog insulin 33 units and head back to the medication cart. On 09/23/25 at 1:19 PM, Surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-07-10 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection. This has the potential to affect all 33 residents residing in the facility. The facility did not implement Standard of Practice (SOP) for documentation of Infection Control Surveillance and Monitoring with isolation precaution type, start date, and stop date. Staff did not perform appropriate hand hygiene with glove use during cares provided to R19 and R16. Findings: Example 1 The facility policy titled, Infection Prevention & Control Surveillance, with most recent review date 03/2024, states in part: The Infection Preventionist will conduct ongoing surveillance for HAIs and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. .the Infection…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-07-10 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, the following elements: An antibiotic stewardship program that includes a system to monitor/review antibiotic use. This has the potential to affect all 33 residents residing in the facility. The facility did not follow a Standard of Practice (SOP) for antibiotic stewardship for antibiotic use for residents on the line list logs from January 2024 through June 2024 line lists. The facility did not implement a SOP for antibiotic stewardship to monitor/review antibiotic usage, outcome measures, and summarizing of antibiotic resistance. The facility did not outline and implement a SOP for antibiotic stewardship concerning mode and frequency of education for prescribing providers and nursing staff on antibiotic use and protocols. R6 was prescribed Keflex for wound infection. Culture and sensitivity results did not indicate sensitivity to Keflex. The facility did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-10 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not conduct a thorough investigation into the abuse or protect from future incidents through education for Resident (R) 16. The facility did not conduct a thorough investigation into the abuse as other residents were not interviewed to determine if other residents were affected. The facility did not protect residents from future incidents as education was not provided to staff after this incident occurred. Findings: The facility's policy titled, Resident Abuse Prevention and Reporting revised 01/2017, states in part: 7. Investigation/Reporting Procedures for actual or suspected abuse/neglect: . i) Plan for interviews of staff and residents as appropriate . k) Depending on the results of the investigation: Corrective actions will be taken to prevent abuse/neglect which may include discipline up to and including terminations, additional education, care plan or policy change. R16 was admitted on [DATE] with diagnoses of hemiplegia (paralysis on one side of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-10 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) was documented accurately related to tube feeding for 2 (R2 and R11) of 13 residents reviewed for MDS resident assessments. Findings include: Example 1: Review of R2's care plan, orders, diagnosis, and progress notes did not indicate R2 received tube feedings while a resident in the facility. Review of R2's electronic medical record (EMR) annual MDS comprehensive resident assessment with an Assessment Reference Date (ARD) of 06/27/24, documented in section K: Swallowing / Nutritional Status K0520 B, R2 was receiving tube feeding while a resident. The documentation indicated the response was locked and signed on 06/28/24 at 4:47 PM. On 07/08/24 at 6:45 PM, Surveyor completed initial tour of facility and observed R2 was not receiving tube feeding services. Example 2: A review of R11's care plan, orders, diagnosis, and progress notes did not indicate R11 received tube feedings while a resident in the facility. A review of R11's EMR annual MDS comprehensive resident assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2024-07-10 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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 activities of daily living were maintained for 1 out of 2 sampled residents (R31). R31 was not ambulated per recommendation of Physical Therapy (PT). This is evidenced by: The facility's policy titled, Restorative Nursing Program (08/2015) states in part, To promote each Residents ability to adapt and adjust to living as independently and safely as possible .To focus on achieving and/or maintaining the Residents optimal physical functioning in activities of daily living. R31 was admitted to the facility on [DATE]. R31's diagnoses included compression fracture of vertebra, low back pain, unspecified, adult failure to thrive, weakness, and muscle weakness (generalized). R31's Minimum Data Set (MDS), dated [DATE], confirmed R31 scored 14 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R31 understands and is understood by others, and she is able to make her needs known. R31 is totally dependent on staff 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.
- Potential for harm · D2024-07-10 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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, record review and interview, the facility did not implement a restorative program in attempt to improve or maintain resident's functional abilities for 1 of 2 residents (R19) reviewed for limited Range of Motion (ROM). Findings: The facility's policy titled, Restorative Nursing Program revised 8/2015, states . Policy To promote each Residents ability to adapt and adjust to living as independently and safely as possible. One Restorative Aide (RA) will be scheduled each day. Purpose To focus on achieving and/or maintaining the Residents optimal physical functioning in activities of daily living. Procedure The director of Nursing or designee will supervise the Restorative Program. An RN will be the Restorative Nursing Coordinator. CNA's specially trained in Restorative procedures will implement, assist, and document the restorative activities for assigned Residents. In-service will be held as needed to train and update staff. R19 was admitted on [DATE] with diagnoses of Alzheimer's, dementia,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-10 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 of 5 residents (R8) were free from unnecessary medications. -R8 was prescribed lorazepam (anti-anxiety) without a documented diagnosis. -R8 was prescribed lorazepam as needed (PRN), beyond the 14-day limit, without a documented rationale. -R8's record did not include interventions to reduce or eliminate the need for administration of medication. -R8's record did not indicate adequate monitoring of anti-anxiety medication, including signs or symptoms to warrant administration of medication, and side effects of the medication. Findings include: R8 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and heart failure. R8's record did not include a diagnosis of anxiety. R8's Minimum Data Set (MDS) assessment completed on 03/25/24, indicated a significant change related to hospice services. R8's most recent MDS assessment completed on 06/12/24 confirmed R8 scored 07/15 during 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.
- Potential for harm · D2024-07-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility did not ensure drugs and biologicals used in the facility are labeled in accordance with current accepted professional principles for 1 of 26 medications reviewed during medication administration observation. This had the potential for harm to affect Resident (R)30. This is evidenced by: R30 was admitted to facility on 12/08/23 with a pertinent diagnosis of diabetes mellitus II. R30 has a prescription order for insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) inject 28 unit subcutaneously one time a day related to type 2 diabetes. On 07/10/24 at 7:50 AM, Surveyor observed Licensed Practical Nurse (LPN) F complete medication administration of insulin to R30. Surveyor observed R30's insulin glargine injection pen had a pharmacy label stating name, received date of 06/14/24, open date of 06/24/24, and dose to be administered of 22 units subcutaneously every AM. Surveyor reviewed physician order and Medication Administration Record (MAR) in R30's Electronic Medical Record (EMR) and noted as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-07 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not revise the care plan with accurate information for safety interventions when the call light was removed for 2 of 2 residents (R) reviewed. (R2 and R3). Findings include: Example 1 R2 was admitted to the facility on [DATE], with diagnoses including unspecified dementia with severe mood disturbance, dysphagia, contracture of right and left knee, muscle weakness, and hypertension. R2's minimum data set (MDS) assessment, completed on 03/14/24, confirmed R2 scored 03 during a brief interview for mental status (BIMS), indicating severely impaired cognition. R2 requires partial/moderate assistance with eating. R2 requires total assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R2's care plan was initiated on 09/06/19, and included the following interventions: ADL SELF-CARE DEFICIT care plan: Encourage the resident to use bell to call for assistance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure residents were safe in their environment to prevent the risk of falling. This occurred for 3 of 3 residents (R) reviewed for falls, (R1, R2, and R3). The facility staff did not ensure R1 had pressure alarm pad while R1 was sitting in recliner as care planned. The facility staff did not ensure brakes were locked on EZ-stand lift during R2's transfer from recliner to bathroom. The facility staff did not ensure R3's recliner leg rest was down, and recliner unplugged as care planned. Findings include: Example 1 R1 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, non-ST elevation myocardial infarction, arthritis, congestive heart failure, muscle weakness, and hypertension. R1's minimum data set (MDS) assessment, completed on 04/10/24, confirmed R1 scored 09 during a brief interview for mental status (BIMS), indicating moderately impaired cognition. R1 requires partial/moderate assistance from staff 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.
- Potential for harm · F2023-08-02 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and kitchen temperature log review, the facility did not ensure the dishwashers were maintained and in safe operating condition. This has the potential to affect all 32 residents. The dishwasher did not reach manufacturer recommended temperatures to effectively sanitize dishes. Findings include: On 08/01/23 at 9:20 AM, Surveyor observed the dishwasher in kitchenette on Harmony House. The dishwasher had been running prior to Surveyor entering the area. Surveyor observed the wash temperature go up to 145 after Dietary Aide (DA) G restarted it 3 times. The dishwasher is a Champion hot water machine. For a high temperature dishwasher (heat sanitization) the wash temperature should be 150 - 165 degrees F. The rinse temperature must indicate a minimum of 180 - 190 degrees. Surveyor asked DA G if the wash cycle gets up to 150. DA G indicated that it has not been. Surveyor asked how long this has been going on. DA G indicated a while. Surveyor observed the dishwasher in the main kitchen; the temperature for the wash was 130. Surveyor then asked Dietary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-02 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not consult with the resident's physician when the resident had a change in condition for 1 of 1 residents reviewed (R27). Physician was not notified of R27's increased pain after a fall with a resident that has a history of fractured cervical vertebra. This is evidenced by: R27 was admitted to the facility on [DATE] and has diagnoses that include fracture of 6th cervical vertebra, anxiety, traumatic brain injury (TBI), fibromyalgia and major depressive disorder. Surveyor reviewed nursing description of fall with injury that occurred on 05/08/23 at 3:10 PM that read in part: .[R27] was seen by [Licensed Practical Nurse (LPN) N] lying on floor in front of [R27] wheelchair in hallway between hall and dining room. [LPN N] evaluated [R27]. [LPN N] observed [R27's] glasses crooked to the side of resident's face, nose bleeding. [R27] was assisted back to wheelchair via hoyer lift and returned to room. RN called. Face cleaned and bridge of nose and left hand…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not ensure residents received care per professional standards of practice. The LPN moved R27 after a significant fall, who had a history of cervical fracture after a fall with injury before Registered Nurse (RN) assessment was completed. Facility did not ensure a resident with chronic wounds received care per professional standards of practice to include weekly wound assessments with description of wound and measurements. This affected 1 of 3 residents looked at for wounds. (R8) This is evidenced by: Example 1 The facility policy, entitled Falls Protocol, dated 05/2019, reads in part If a resident had fallen or is observed on the floor without a witness to the event, nursing staff will evaluate for possible injuries to the head, neck, spine and extrmidies [sic]. R27 was admitted to the facility on [DATE] and has diagnoses that include fracture of 6th cervical vertebra, anxiety, traumatic brain injury (TBI), fibromyalgia and major depressive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not initiate interventions to prevent weight loss for 1 of 1 resident (R17) reviewed for weight loss. R17 had a significant weight loss from 01/01/23 to 07/01/23 and no interventions were documented in the medical chart. Findings include: The facility policy, entitled Weights (Resident), revised 06/2018, states: Weight Assessment: .4. The Dietitian and Dietary manager will review resident weights monthly to follow individual weight trends over time. 5. The threshold for significant unplanned and undesired weight loss will be base on the following criteria [where percentage of body weight loss= (usual weight-actual weight)/(usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. .Care Planning: 1. Individualized care plans shall address to the extent possible: a.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-02 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not ensure residents using psychotropic drugs received a gradual dose reduction (GDR), had indication for use, or monitoring for adverse side effects for 1 of 3 residents (R27) reviewed for psychotropic medications. Facility did not have a clinical rationale for not attempting a GDR for R27's antipsychotic medication, or documentation of behaviors for indication for use, or monitoring of side effects for adverse effects of the medication. This is evidenced by: R27 was admitted to the facility on [DATE] and has diagnoses that include fracture of 6th cervical vertebra, anxiety, traumatic brain injury (TBI), fibromyalgia and major depressive disorder. R27 has a doctor's order for Risperidone tablet 0.5 MG by mouth two times a day. On 04/04/23, the pharmacist made a recommendation for a GDR. Nurse Practitioner (NP) L declined the recommendation and wrote in part, .benefits outweigh the risks. Surveyor interviewed Director of Nursing (DON) B and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-02 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 observations and interviews, the facility did not distribute and serve food in accordance with professional standards for food service safety. This had the potential to affect 3 residents who are on a pureed diet. Facility did not check temperature of pureed foods or document temperature of pureed food. Findings include: On 08/01/23 at 11:19 AM, Surveyor observed [NAME] H checking temperatures of food in main kitchen before sending out to the kitchenette. [NAME] H had checked all the regular diet food and it was within normal temperature range. [NAME] H put food in the hot cart to go to the kitchenette to be served. [NAME] H then pulled out pureed food from the microwave and put into metal containers and was putting them directly into the hot cart. Surveyor asked [NAME] H if they check the temperatures of the pureed foods. [NAME] H indicated that they usually don't because they had it in the microwave and don't have to write it down. [NAME] H indicated that they would check it for Surveyor though and pulled the metal containers out of the hot cart and checked temperature of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-02 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This affected 3 of 12 sampled residents. Staff did not wear proper personal protective equipment (PPE) when doing wound care for a resident (R) on enhanced barrier precautions (EBP) and did not sanitize bandage scissors prior to cutting dressings. This affected 1 of 3 residents observed for wound care. (R8) Staff did not perform hand hygiene prior to putting on gloves during medication administration for R27. Staff did not perform hand hygiene between glove changes during cares during 1 of 3 observations of cares. This affected R4. Findings include: Example 1 R8 was admitted to the facility on [DATE] with a chronic non-pressure ulcer to the right lower leg. On 07/31/23 at 10:40 AM, Surveyor observed a sign on R8's bathroom door stating: Enhanced Barrier Precautions .Providers and Staff must…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2025-09-26 for 21 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ADAIR, CRAIG | Individual | CORPORATE DIRECTOR | since 06/12/2006 |
| ANDRESS, JAY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/18/2026 |
| GILHOI, SUE | Individual | CORPORATE DIRECTOR | since 06/12/2023 |
| JOHNSON, DALE | Individual | CORPORATE DIRECTOR | since 02/17/2004 |
| PROSE, DONALD | Individual | CORPORATE DIRECTOR | since 06/12/2017 |
| ROWE, BRUCE | Individual | CORPORATE DIRECTOR | since 06/10/2024 |
| BROTEN, MICHAEL | Individual | CORPORATE OFFICER | since 08/01/2023 |
| GLAIM, STEVE | Individual | CORPORATE OFFICER | since 06/28/2016 |
| JORGENSEN, BARBARA | Individual | CORPORATE OFFICER | since 09/03/2024 |
| ROESCHEN'S HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/15/2025 |
| UNITED PIONEER HOME INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF | since 02/17/2025 |
| QUICK, JANE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/12/2015 |
| SCHULTZ, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/15/2015 |
CMS files one row per role, so the 18 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525680. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-24, 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.