River's Bend Health Services
960 S Rapids Rd, Manitowoc, WI 54220 · For profit - Corporation · 100 certified beds · (920) 684-1144 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.9% | 16.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.1% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.0% | 2.1% | 0.9% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 2.7% | 2.0% | better |
| Long-stay residents with depressive symptoms | 6.7% | 5.7% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.9% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 31.2% | 18.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 26.2% | 16.9% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 93.3% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 5.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.2% | 24.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.2% | 15.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 67.3% | 82.2% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.6% | 23.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 29.0% | 15.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.74 | 1.66 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.68 | 2.29 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
52.2% 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 70 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 36.4% 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 33 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 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 52.2%CMS range 41.7–66.0 | 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 | 10.1%CMS range 6.5–14.4 | 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 | 36.4% | 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 | 33.3% | 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 | 12.1% | 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 | 95.7% | 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 | 95.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 6.4% | 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 | 6.3%CMS range 3.9–11.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.70 | 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 100 beds and averages 83.8 residents a day — about 84% occupied, or roughly 16 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.30 hrs/resident/day on weekends vs 3.67 on weekdays — 10% thinner on weekends. RN hours go from 0.76 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · Dcited before2026-07-02 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility did not report allegations of abuse in a timely manner for 5 residents (R) (R2, R3, R4, R5, and R6) of 10 sampled residents. On 1/27/26, staff witnessed (Certified Nursing Assistant)5 display rude, loud, and rough behavior toward R6. Interviews determined R2, R3, R4, and R5 experienced similar behavior by CNA5 that day. The allegations of abuse were not reported in a timely manner.Findings include: Review of the facility's All Staff Abuse, Neglect policy, dated 7/15/22, revealed: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies within specified timeframes: Immediately, but not later than 2 hours…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-28 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 (Certified Nursing Assistant (CNA)-C) of 8 employees reviewed for caregiver background checks.The facility did not complete a thorough background check for CNA-C prior to hire.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks, including re-checks, will be completed consistent with applicable state laws and regulations. Responsibility of performance of compliance checks on contracted temporary staff will be established via contractual agreement. 2. Screenings may be conducted by the facility itself, a third-party agency, or academic institution. 3. The facility will…
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 before2026-01-28 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not report an allegation of neglect to the State Agency (SA) for 1 resident (R) (R1) of 7 sampled residents.An allegation of neglect that occurred on 12/23/25 and involved R1 and Certified Nursing Assistant (CNA)-E was reported to Nursing Home Administrator (NHA)-A. NHA-A did not report the allegation of neglect to the SA.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .2. The facility will designate a leadership position in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state Survey Agency and other officials in accordance with state law .VII. Reporting/Response. A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services (APS), and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: 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 before2026-01-28 · 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 staff interview and record review, the facility did not thoroughly investigate an allegation of neglect for 1 resident (R) (R1) of 7 sampled residents.An allegation of neglect that occurred on 12/23/25 and involved R1 and Certified Nursing Assistant (CNA)-E was reported to Nursing Home Administrator (NHA)-A. The facility did not thoroughly investigate the allegation of negelct.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .2. The facility will designate a leadership position in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state Survey Agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to ensure that its policies are implemented as written .V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-18 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 1 resident (R) (R48) of 19 sampled residents had the right to make healthcare decisions in accordance with applicable law.R48 was admitted to the facility without an activated Power of Attorney for Healthcare (POAHC) and was not provided the right to sign consent for admission or an advance directive that indicated R48 did not wish to be resuscitated (DNR). In addition, R48's Power of Attorney (POA) paperwork did not allow R48's designated health care agent to admit R48 to long-term care for longer than a short-term stay.Findings include:Wisconsin Chapter 155.05(2) indicates: Unless otherwise specified in the power of attorney for health care instrument, an individual's power of attorney for health care takes effect upon a finding of incapacity by 2 physicians, as defined in s. 448.01(5), or one physician and one licensed advanced practice clinician, who personally examine the principal and sign a statement specifying that the principal has…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R3 and R41) of 19 sampled residents received staff assistance as needed to complete activities of daily living (ADLs).R3 did not receive weekly showers as scheduled.R41 did not receive weekly showers as scheduled.Findings include:The facility's Activities of Daily Living (ADLs) policy, dated 7/26/22, indicates: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. The care and services will be provided for the following ADLs: 1. Bathing, dressing, grooming and oral care .3. A resident who is unable to carry out ADLs will receive the necessary treatment to maintain good nutrition, grooming, and personal and oral hygiene .1.From 12/16/25 to 12/18/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE], received…
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 · D2025-12-18 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a pneumococcal vaccine was offered for 1 resident (R) (R5) of 5 sampled residents.R5 was not offered the PCV20 vaccine per the facility's policy.Findings include:The facility's Pneumococcal Vaccine (Series) policy, revised 3/25/25, indicates: Each resident will be assessed for pneumococcal immunization upon admission .2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized .6. The type of pneumococcal vaccine (PCV15, PCV20, PCV21, or PPSV23) offered will depend upon the recipient's age, certain risk conditions, and previously received pneumococcal vaccines, in accordance with current Centers for Disease Control and Prevention (CDC) guidelines and recommendations. On 12/16/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including infection and inflammatory reaction due to internal right knee prosthesis…
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 · D2025-12-18 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a COVID-19 vaccine was offered for 1 resident (R) (R5) of 5 sampled residents.R5 was not offered a COVID-19 vaccine per the facility's policy.Findings include:The facility's COVID-19 Vaccination policy, dated 9/13/24, indicates: It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine.On 12/16/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including infection and inflammatory reaction due to internal right knee prosthesis and type 2 diabetes. R5's Minimum Data Set (MDS) assessment, dated 12/5/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. R5 was R5's own decision maker. R5's medical record indicated R5's last COVID-19 vaccination was on 10/11/24. R5's medical record did…
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 before2025-11-24 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff and resident interview and record review, the facility did not report an allegation of abuse to the State Agency (SA) for 1 resident (R) (R1) of 1 sampled resident.R1 reported an allegation of staff-to-resident abuse. The facility did not report the allegation of abuse to the SA.Findings:The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Reporting/Response: The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services (APS), and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily…
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 before2025-11-24 · 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
Based on staff and resident interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R1) of 1 sampled resident. R1 reported an allegation of staff-to-resident abuse. The facility did not thoroughly investigate the allegation of abuse.Findings include:The facility's Abuse, Neglect, and Exploitation policy, dated 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .V. Investigation of Alleged Abuse, Neglect, and Exploitation: A. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or exploitation or reports of abuse, neglect, or exploitation occur. B. Written procedures for investigations include: Identifying staff responsible for the investigation, exercising caution in handling evidence that could be used in a criminal investigation…
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 17 citations
- Potential for harm · D2025-07-01 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
Based on observation, staff interview, and record review, the facility did not provide a safe, clean, comfortable, and home-like environment for 1 resident (R) (R3) of 3 sampled residents.The facility did not ensure dirt, debris, food, and spills on R3's floor were cleaned in a timely manner.Findings include: The facility's Resident/Patient Room Cleaning policy, dated 2/1/25, indicates: (The facility's contracted company) is committed to providing a safe, clean, and hygienic environment for residents, staff, and visitors in accordance with regulatory guidance and industry best practices. This policy applies to all environmental services staff under the direction of (the contracted company) and supplements facility policies only where (the contracted company) has assumed responsibility for environmental services operations Floors will be dust mopped, then damp mopped, and any carpet vacuumed in a manner consistent with accepted infection control practices . On 7/1/25, Surveyor reviewed R3's medical record. R3 had diagnoses including dementia, end-stage renal disease on hemodialysis,…
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 · D2025-02-17 · 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 staff interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) was notified of a fall for 1 resident (R) (R2) of 4 sampled residents. R2 had a witnessed fall on 12/4/24. R2's POAHC (POAHC-G) was not notified of the fall in a timely manner. Findings include: The facility' Fall Prevention and Management Guidelines policy, dated 7/18/24, indicates: When any resident experiences a fall, the facility will .Notify the physician and family/responsible party. Review the resident's care plan and update with any new interventions put in place to try to prevent additional falls . On 2/17/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including dementia, ischemic stroke, pulmonary hypertension, and chronic diastolic heart failure. R2's Minimum Data Set (MDS) assessment, dated 12/4/24, indicated R2 had intact cognition. R2 had a POAHC that was activated on 11/23/24. R2's care plan, dated 11/30/24, indicated R2 was at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-17 · 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 staff interview and record review, the facility did not individualize and revise the comprehensive plan of care for 1 resident (R) (R2) of 4 sampled residents. R2's plan of care did not indicate R2's activities of daily living (ADL) needs. In addition, R2's plan of care was not updated after a fall on 12/4/24. Findings include: The facility's Fall Prevention and Management Guidelines policy, dated 7/18/24, indicates: .When any resident experiences a fall, the facility will .review the resident's care plan and update with any new interventions put in place to try to prevent additional falls . The facility's Change in Condition of the Resident policy, dated 12/2016, indicates: When a resident presents with a possible change of condition .update the plan of care as needed . On 2/17/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including dementia, ischemic stroke, pulmonary hypertension, and chronic diastolic heart failure. R2's Minimum Data Set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-28 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with the facility's policy. One of 5 medication carts was unlocked and unattended. and 3 of 5 medication carts and 2 of 3 medication storage rooms contained expired medication and medical supplies. In addition, the facility did not ensure an inhaler was labeled in accordance with the manufacturer's recommendations for 1 Resident (R) (R45) of 6 sampled residents observed during medication administration. This practice had the potential to affect more than 4 of the 69 residents residing in the facility. On 8/26/24, a medication cart on the 100 wing was unlocked and unattended. On 8/26/24, medication carts and medication storage rooms contained expired medications and medical supplies. On 8/27/24, staff administered an undated inhaler to R45. Findings include: The facility's Medication Storage policy, dated 1/2024, indicates: Medications and biologicals are stored…
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 · E2024-08-28 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
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 resident and staff interview, the facility did not consistently provide or offer a substantial evening snack to residents. The timeframe from the supper meal to the breakfast meal was greater than 14 hours. This had the potential to affect more than 4 of the 69 residents residing in the facility. A substantial snack was not regularly offered to residents which created a gap of more than 14 hours between the supper and breakfast meals. Findings include: The facility did not provide a snack policy. On 8/26/24 at 9:12 AM, Surveyor began an initial kitchen tour. During the tour, Dietary Manager (DM)-I stated the facility did not have a regular snack cart or snack pass. DM-I stared staff could enter the kitchen and make a sandwich or retrieve what was requested for a snack. DM-I stated the kitchen used to put more snacks in the nourishment room and on the drink carts, but there was an issue with the snacks disappearing. DM-I also stated some residents took snacks and didn't eat them which resulted in snacks…
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 before2024-08-28 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect more than 4 of the 69 residents residing in the facility. The 300 unit refrigerator was not in a clean condition and contained items that were not labeled or dated and were expired. In addition, the refrigerator temperature log was not completed and items in the nourishment room were not labeled or dated. Milk and juice were not held at a cold temperature during lunch service. Findings include: On 8/26/24 at 9:00 AM, Surveyor began an initial tour of the kitchen with Dietary Manager (DM)-I who stated the facility followed the Wisconsin (WI) Food Code as its standard of practice. The WI Food Code documents at 3-501.17 Ready-to-Eat, Potentially Hazardous Food (Time/Temperature Control for Safety Food), Date Marking: (A) Refrigerated, ready-to-eat, potential hazardous food (time/temperature control for safety food) prepared 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 · Ecited before2024-08-28 · 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, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection. This had the potential to affect more than 4 of the 69 residents residing in the facility. R36 was on enhanced barrier precautions (EBP) due to a permacath. On 8/27/24, staff did not wear personal protective equipment (PPE) during high-contact resident care. In addition, there was not a sign posted near R36's room that indicated R36 was on EBP. On 8/27/24, staff transported unbagged soiled linens in a resident hallway. Findings include: The facility's Enhanced Barrier Precautions policy, with a revision date of 8/8/24, indicates: Implementation of Enhanced Barrier Precautions: .b. Personal protective equipment for enhanced barrier precautions is only necessary when performing high-contact care activities .High-contact resident care activities include: a. dressing .c. transferring . The facility's contracted service's Handling, Transporting and Storage of Laundry policy, with a revision date…
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 · D2024-08-28 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure a physician's order was obtained and a self-administration of medication assessment was completed for 1 Resident (R) (R68) of 7 sampled residents. On 8/26/24, Registered Nurse (RN)-K left medication at R68's bedside for R68 to self-administer. R68 did not have a physician's order or self-administration of medication assessment that indicated R68 could safely and accurately self-administer medication. Findings include: The facility's Resident Self-Administration by Resident policy, dated 1/2023, indicates: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's Interdisciplinary Team has determined the practice would be safe, and the medications are appropriate and safe for self-administration. From 8/26/24 to 8/28/24, Surveyor reviewed R68's medical record. R68 was admitted to the facility on [DATE] with diagnoses including non-infective…
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 · D2024-08-28 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility did not ensure 2 Residents (R) (R223 and R173) of 4 sampled residents signed and received copies of the Notice of Medicare Non-Coverage (NOMNC) form and/or Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form which are used to inform residents of their final day of Medicare Part A insurance coverage, potential liability for payment (daily cost of care and services at the facility), and standard claim appeal rights and instructions. The facility did not provide an ABN form (a document that explains financial liability, including the facility's daily rate for services) to R223 when R223's Medicare benefits ended on 2/25/23 and R223 remained in the facility. The facility did not provide a NOMNC form (used to inform Medicare beneficiaries when their covered services are ending and their appeal rights) to R173 at least two calendar days before R173's Medicare services ended. Findings include: The Centers for Medicare and Medicaid Services (CMS) form CMS-10123 indicates a NOMNC form must be delivered at least two calendar…
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 · D2024-08-28 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure 3 Residents (R) (R223, R20, and R70) of 3 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R223 was transferred to the hospital on 1/26/23. Neither R223 or R223's emergency contact were provided with a written transfer notice for R223's hospital transfer. R20 was transferred to the hospital on 5/17/24. Neither R20 or R20's emergency contact were provided with a written transfer notice for R20's hospital transfer. R70 was transferred to the hospital on 5/23/24. Neither R70 or R70's emergency contact were provided with a written transfer notice for R70's hospital transfer. Findings include: The facility's Transfer and Discharge policy, with a revision date of 7/15/22, indicates: It is the policy of the facility to permit each resident 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 · D2024-08-28 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure 3 Residents (R) (R223, R20, and R70) of 3 residents reviewed for hospitalization received notified of the facility's bed hold policy when transferred to the hospital. R223 was transferred to the hospital on 1/26/23. Neither R223 or R223's emergency contact were provided with a bed hold notification for R223's hospital transfer. R20 was transferred to the hospital on 5/17/24 and 7/31/24. Neither R20 or R20's emergency contact were provided with a bed hold notification for R20's hospital transfers. R70 was transferred to the hospital on 5/23/24. Neither R70 or R70's emergency contact were provided with a bed hold notification for R70's hospital transfer. Findings include: The facility's Transfer and Discharge policy, with a revision date of 7/15/22, indicates: It is the policy of the facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except as .necessary 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 · D2024-08-28 · 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 2. From 8/26/24 to 8/28/24, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had diagnoses including morbid obesity, mild intermittent asthma, type 2 diabetes, and edema. R21's MDS assessment, dated 6/11/24, had a BIMS score of 13 out of 15 which indicated R21 had intact cognition. R21 had orders for Lasix (a diuretic medication) for edema and daily weight monitoring. R21's nutrition care plan, with a revision date of 6/8/21, contained an intervention to review weights and notify the Medical Doctor (MD) and responsible party of significant weight changes. On 8/26/24 at 9:55 AM, Surveyor interviewed R21 who stated R21 had concerns related to dining and nutrition. R21's medical record indicated R21 had physician orders for daily weight monitoring as of 3/12/23 and was prescribed 60 mg (milligrams) of Lasix in the AM. The daily weights and Lasix were prescribed for edema. R20's Medication Administration Record (MAR) indicated staff should monitor R21 for new symptoms 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 · D2024-08-28 · 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 staff and resident interview and record review, the facility did not maintain continuous positive airway pressure (CPAP)/biphasic positive airway pressure (BiPAP) equipment per the facility policy and manufacturer's recommendations for 1 Resident (R) (R21) of 1 sampled resident. R21 had a CPAP/BiPAP machine for obstructive sleep apnea. R21 did not have a cleaning schedule for the machine/equipment or instructions for filling the humidifying chamber. Findings include: The facility's CPAP therapy policy, with a reviewed/revised date of 6/24/24, indicates: Cleaning and Maintenance: .7. Clean and inspect all components regularly .8. Clean CPAP unit as necessary . ResMed (brand of CPAP/BiPAP machine) recommendations for cleaning CPAP/BiPAP machines are as follows: Mask clean daily, cushion clean daily, headgear clean daily or weekly, frame clean daily or weekly, air tubing clean weekly, humidifier chamber clean daily and soak weekly, CPAP machine clean weekly, air filers check weekly for damage. Rinse 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 · D2024-01-17 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R1) of 5 sampled residents was free from a significant medication error. R1 had a physician order, dated [DATE], to hold R1's 125 microgram (mcg) digoxin tablet (administered once daily for heart failure) and repeat laboratory blood work due to an elevated digoxin level. The order did not contain a duration or time frame. The order was not transcribed or clarified and R1 received 125 mcg of digoxin daily from [DATE] through [DATE]. Findings include: The facility's Medication Orders policy, with a revision date of 1/2023, contained the following information: .2. Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the Physician Order Sheet (POS) Telephone Order Sheet (TO) if it is a verbal order, and on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) . On [DATE], Surveyor reviewed…
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 before2023-07-26 · 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, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 62 residents residing in the facility. Staff did not test Quaternary sanitizing solution per manufacturer's instructions. Kitchen preparation areas were not clean. Warewashing temperatures were not monitored to ensure manufacturer's minimum wash and rinse temperatures were achieved to prevent the spread of foodborne illness. Food holding temperatures were not monitored or documented. Findings include: On 7/24/23, Nursing Home Administrator(NHA)-A verified the facility contracts with Healthcare Services Group, Inc for all dietary staff. On 7/24/23, Dietary Manager (DM)-D indicated the facility followed the Federal Food and Drug Administration (FDA) Food Code as its standard of practice. Sanitizing Solution Health Services Group, Inc. Cleaning and Sanitizing policy indicated the following: Working in a nursing facility and keeping residents safe is a huge undertaking and keeping areas sanitized is 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 · Ecited before2023-07-26 · 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, staff interview, and record review, the facility did not provide a sanitary environment to help prevent the transmission of communicable disease and infection for Resident (R) (R57) and multiple other residents in the facility. Multiple residents were not offered hand hygiene prior to meal service in the dining room on 7/24/23 and 7/25/23. Multiple residents were not offered hand hygiene prior to meal service on the 100 unit on 7/24/23. Certified Nursing Assistant (CNA)-H did not perform hand hygiene or change soiled gloves during the provision of care for R57. In addition, R57's Foley catheter drainage bag was observed on the floor without a barrier between the bag and the floor. Findings include: The facility's Hand Hygiene policy, dated 11/2/22, indicated: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .6. Additional Considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (putting on) gloves,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-26 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a Power of Attorney for Health Care (POAHC) document was obtained or offered to create (in the absence of an existing document) for 2 Residents (R) (R48 and R50) of 17 sampled residents. R48 was admitted to the facility in February of 2022. R48 did not have a POAHC document in R48's medical record. R50 was admitted to the facility in March of 2022. R50 did not have a POAHC document in R50's medical record. Findings include: The Department of Health Services Instructions to Complete the Power of Attorney for Health Care Form state, The Power of Attorney for Health Care Form makes it possible for adults in Wisconsin to authorize individuals (called health care agents) to make health care decisions on their behalf should they become incapacitated. It may also be used to make or refuse to make an anatomical gift (donation of all or part of the human body to take effect upon the death of the donor). 1. On 7/25/23 at 8:35 AM, Surveyor reviewed…
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.
Part of a chain
This home belongs to NORTH SHORE HEALTHCARE — 59 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.7 | +0.3 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 3 of 5 | 3.4 | -0.4 vs chain |
| Quality measures | 2 of 5 | 2.5 | -0.5 vs chain |
The other 58 homes this chain runs (chain average 2.7★, per CMS)
Showing 40 of 58; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NSHF OPERATIONS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/24/2017 |
| MILLS, DAVID | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 20% | since 08/29/2017 |
| BAUMANN, TROY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | — | since 06/29/2017 |
| HOEHN, JEFFREY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 06/29/2017 |
| NORTH SHORE HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/07/2017 |
CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
This home reported $378K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 525475. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-18, 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 →
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