Luther Home
831 Pine Beach Rd, Marinette, WI 54143 · Non profit - Corporation · 80 certified beds · (715) 732-0155 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2026
- 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 11.9% | 16.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.2% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 5.3% | 2.1% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 2.7% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.6% | 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 | 3.8% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 12.7% | 18.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.0% | 16.9% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 5.0% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 21.7% | 24.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.1% | 15.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 92.0% | 82.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 12.9% | 23.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.1% | 15.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.02 | 1.66 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.35 | 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.
44.1% 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 80 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 77.1% 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 35 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 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | 44.1%CMS range 34.0–60.4 | 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 | 13.0%CMS range 9.4–18.2 | 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 | 77.1% | 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 | 62.9% | 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 | 65.7% | 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 | 100.0% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.6%CMS range 4.0–12.8 | 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 80 beds and averages 59.4 residents a day — about 74% occupied, or roughly 21 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 4.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.81 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.86 hrs/resident/day on weekends vs 4.24 on weekdays — 9% thinner on weekends. RN hours go from 0.78 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · Dcited before2026-07-01 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the right to be free from verbal abuse by staff for 1 resident (R) (R4) of 4 residents in a total sample of 8 residents.Staff witnessed Certified Nursing Assistant (CNA)2 be verbally abusive to R4.Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, reviewed September 2024, revealed: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Causes could reasonably be expected to cause mental or emotional damage to a client, including harm to client's psychologic or intellectual functioning that is exhibited by anxiety, depression, withdrawal, regression, outward aggressive behavior, agitation, or fear of harm or death, or a combination of these behaviors. Review of the Face Sheet tab located in the electronic medical record (EMR) revealed R4 was admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 residents (R) of the 61 residents residing in the facility. The facility did not ensure transmission-based precautions (TBP) were implemented for R53 for Norovirus (The most common cause of gastroenteritis, characterized by non-bloody diarrhea, vomiting, and stomach pain. The virus is highly contagious and spread through contaminated food or water or person-to-person contact, contaminated surfaces, or through air from the vomit of an infected person.) Licensed Practical Nurse (LPN)-K did not complete appropriate hand hygiene during medication administration.Housekeeper (HK)-G did not use appropriate disinfecting solution to mop residents' floors on a unit with a Norovirus outbreak. In addition, the housekeeping department did not have 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 · D2025-12-10 · 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) (R8) of 1 sampled resident with a Guardian was protectively placed at the facility. R8 had a legal Guardian at the time of admission on [DATE]. R8's medical record included an order for Guardianship of person and estate dated 9/21/22. R8's medial record did not contain an order for protective placement.Findings include:State Statute Chapter 55.03(4) indicates: The law requires a court-ordered protective placement for any resident admitted to a nursing home who has a legal Guardian and whose nursing home stay exceeds sixty days, only to be extended with court approval (State Statute Chapter 55.05(b)). Protective placement is reviewed annually (State Statute Chapter 55.18) to determine if placement continues to be least restrictive and in the best interest of the individual.On 12/8/25, Surveyor reviewed R8's medical record. R8 had diagnoses including schizophrenia, seizure disorder, and anxiety disorder. R8's Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-10 · 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) (R2 and R22) of 2 sampled residents were provided a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form which is used to inform residents of the potential liability for payment (daily cost of care and services at the facility).The facility did not provide an ABN form to R2 when R2's Medicare Part A benefits ended on 10/10/25 and R2 remained in the facility. The facility did not provide an ABN form to R22 and when R22's Medicare Part A benefits ended on 11/25/25 and R22 remained in the facility. Findings include:The Centers for Medicare & Medicaid Services (CMS)-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (ABN) form indicates: The ABN provides information to the beneficiary so the beneficiary can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility .The ABN is only issued if the beneficiary intends to continue services and the skilled nursing facility believes the services may not be covered under…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-10 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R2) of 3 sampled residents was free from abuse.The facility was aware of verbal abuse directed at R2 by R2's activated Power of Attorney for Healthcare (POAHC) on 10/16/25. An investigation was not completed and the facility did not implement measures to protect R2 from future abuse. A second occurrence of verbal abuse directed at R2 by POAHC-M occurred on 12/8/25. Findings include: The facility's Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, revised June 2025, indicates: .You as an individual employee have a moral and legal responsibility to make sure each resident is free from abuse. The Administration of this facility takes very serious this duty. Abuse, in general, is any act that inflicts physical, emotional, or mental harm upon a resident .abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish From 12/8/25 to 12/10/25, Surveyor reviewed R2's…
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 · D2025-12-10 · 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 ensure an allegation of verbal abuse was reported to the State Agency (SA) for 1 resident (R) (R2) of 3 sampled residents. On 10/16/25, the facility was informed of an allegation of verbal abuse toward R2 by R2's activated Power of Attorney for Healthcare (POAHC). The allegation of abuse was not reported to the SA. Findings include: The facility's Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, revised June 2025, indicates: .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Reporting Abuse: It is the responsibility of our employees, attending physicians, family members, visitors, volunteers, contractors, etc., to immediately report any incident or suspected incident of neglect or physical or verbal resident abuse .to the Administrator or his/her designee Immediately means upon witnessing an incident or as soon 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 · Dcited before2025-12-10 · 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 staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R2) of 3 sampled residents. On 10/16/25, the facility became aware of an allegation of verbal abuse toward R2 by R2's activated Power of Attorney for Healthcare (POAHC). The allegation of abuse was not thoroughly investigated. Findings include: The facility's Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, revised June 2025, indicates: .All reports of resident abuse, neglect, and injuries of unknown source shall be immediately and thoroughly investigated .1. Should an incident or suspected incident of abuse, neglect, or injury of an unknown source be reported, the Administrator and/or his/her designee will investigate the alleged incident. 2. The individual(s) conducting the investigation will, at a minimum, and when necessary: a. Review the resident's medical record to determine events leading up to the incident; b. Interview 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 · D2025-12-10 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 provide Preadmission Screening and Resident Review (PASRR) services for 1 resident (R) (R8) of 24 sampled residents. The facility did not contact the state mental health authority to pursue PASRR Level I or II screening for R8 who had a mental illness diagnosis.Findings include:The facility's Resident Assessment-Coordination with PASRR Program policy, revised June 2023, indicates: The facility coordinates assessments with the Preadmission Screening and Resident Review (PASRR) program under Medicaid to the maximum extent practicable to avoid duplicative testing and effort. All individuals with a mental disorder or intellectual disability who apply for admission to the facility will be screened in accordance with the state's Medicaid rules for screening. The facility will only admit individuals with a mental disorder or intellectual disability who the state mental health or intellectual disability authority has determined as appropriate for admission…
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 · D2025-12-10 · 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 staff interview and record review, the facility did not provide care and treatment in accordance with professional standards of practice for 1 resident (R) (R1) of 22 sampled residents. The facility did not accurately document and treat R1's injured right ankle after R1 was lowered to the ground on 11/16/25. Findings include: The facility's Falls: Prevention/Management/Documentation policy, dated January 2009, indicates: .Successful management of falls includes a variety of facility-wide and individual approaches in order to reduce the risk for falls and fall-related injuries to the residents of this facility .A fall occurs whenever unplanned movement from a higher level to a lower level occurs. This includes lowering a resident to the floor to prevent injury from an uncontrolled downward movement .5. All falls will be recorded on the 24-hour report board and follow-up assessment will continue for three shifts. Follow-up will include: vital signs, check for injury, and changes in range of motion 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 · D2025-12-10 · 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, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R41) of 22 sampled residents.The facility did not ensure R41's Average Volume Assured Pressure Support (AVAPS) machine was in working condition and did not follow orders to apply R41's AVAPS machine while sleeping.Findings include:The [NAME] Medical (which makes R41's AVAPS model - [NAME] LM150TD) User Guide indicates: .2.1.1 c. Always keep an alternative means of ventilation available in order to avoid life threatening situations if the device fails .According to Zimnoch et al. in the Journal of Clinical Medicine an article on Non-Invasive Ventilation (NIV), published [DATE]: Non-invasive ventilation modalities such as continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), and AVAPS are a cornerstone in the management of acute and chronic respiratory failure. Inappropriate discontinuation or lack of NIV support when…
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 15 citations
- Potential for harm · D2025-12-10 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 the accurate and safe administration of medication for 2 residents (R) (R25 and R41) of 22 sampled residents.Medications were observed on a table in R25's room. R25 did not have a self-administration of medication assessment that indicated R25 could safely and accurately self-administer medication. In addition, R25 did not have physician orders for the medications.Medications were observed on R41's counter. R41 did not have a self-administration of medication assessment that indicated R41 could safely and accurately self-administer all of the medications. In addition, R41 did not have a physician order for 1 of the medications.Findings include: The facility's Self-Administration of Medication policy, dated 8/2008, indicates: .1. If the resident chooses to self-administer drugs, the Interdisciplinary Team (IDT) must assess the resident's cognitive, physical, and visual abilities to carry out this responsibility. 2.…
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 before2024-10-30 · 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 family representative interview, staff interview and record review, the facility did not notify a Power of Attorney for Healthcare (POAHC) about an allegation of abuse for 1 resident (R) (R1) of 3 sampled residents. On 8/30/24, Certified Nursing Assistant (CNA)-E alleged Licensed Practical Nurse (LPN)-D pushed R1 back into R1's wheelchair when R1 attempted to stand up. Staff did not notify R1's POAHC of the allegation of abuse. Findings include: The facility's Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, revised 6/20/21, indicates: Abuse Investigations .8) The Administrator will keep the resident and/or his/her representative informed of the progress of the investigation .11) The administrator will inform the resident and/or his/her representative of the results of the investigation and corrective action taken within 4 working days of the completion of the investigation. On 10/30/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [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 · D2024-10-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not implement policies and procedures that prohibit and prevent abuse for 1 (Licensed Practical Nurse (LPN)-D) of 1 contracted staff reviewed for a caregiver background check. The facility did not ensure a thorough and timely caregiver background check was completed for LPN-D. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a review date of September 2024, indicates: Not only does the mission of our organization demand that residents be free from abuse, but so do Wisconsin and Federal regulations .In order to comply with the requirements of the Elder Justice Act, [NAME] Home will .4) Refrain from employing any individual who has been prohibited from a long-term care facility because of failure to report a suspicion of a crime against a resident of a long-term care facility. LPN-D was hired on 10/27/23. On 10/30/24 at 3:30 PM, Surveyor requested LPN-D's caregiver background check information from Nursing Home Administrator…
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 before2024-10-30 · 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 ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R1) of 3 sampled residents. On 8/30/24, Certified Nursing Assistant (CNA)-E alleged Licensed Practical Nurse (LPN)-D pushed R1 back into R1's wheelchair when R1 attempted to stand up. LPN-D was not provided abuse education prior to returning to resident care on 9/13/24. Findings include: The facility's Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, revised 6/20/21, indicates: Abuse Investigations .6) Employees of [NAME] Home who have been accused of resident abuse will be suspended from duty until the Administrator has reviewed the results of an investigation. If it is determined that an employee requires any training, the training must be completed before the employee is allowed to return to work. On 10/30/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease,…
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 before2024-08-21 · 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 in a sanitary manner. This practice had the potential to affect multiple residents residing in the facility. Kitchen equipment and food storage areas were not in a clean and sanitary condition. Findings include: On 8/19/24 at 9:15 AM, Kitchen Supervisor (KS)-D stated the facility follows the Food and Drug Administration (FDA) Food Code. The 2022 FDA Food Code documents at 3-305.11 Food Storage: Except as specified in paragraph (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 centimeters (6 inches) above the floor. The 2022 FDA Food Code documents at 3-305.12 Food Storage, Prohibited Areas: Food may not be stored: .(F) Under sewer lines that are not shielded to intercept potential drips; (G) Under leaking water lines, including leaking automatic fire…
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 · D2024-08-21 · 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 interview and record review, the facility did not ensure 3 Residents (R) (R31, R30, and R32) of 3 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. In addition, the facility did not notify the Ombudsman of the transfers. R31 was transferred to the hospital on 1/16/24 and 6/5/24. R31, R31's representative, and the Ombudsman were not provided with written notice of the transfers. R30 was transferred to the hospital on 6/8/24. R30, R30's representative, and the Ombudsmen were not provided with written notice of the transfer. R32 was transferred to the hospital on 8/19/24. R32, R32's representative, and the Ombudsmen were not provided with written notice of the transfer. Findings include: The facility's Transfers and Discharges document, dated 12/1/08, indicates: As members of the Interdisciplinary Team, Social Services staff will participate in all…
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 · D2024-08-21 · 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
Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R31) of 3 residents reviewed for hospitalization received written information of the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R31 was transferred to the hospital on 1/16/24 and 6/5/24. R31 and/or R31's representative were not provided with a bed hold notification. Findings include: The facility's Bed Hold document, dated April 2018, indicates: It is the practice and policy of the facility that all residents upon discharge will be notified of his/her right to hold a bed .Upon transfer, the charge nurse on duty will write the resident's name and current date on the bed hold agreement. The charge nurse will send the yellow copy with the resident at the time of the transfer. The charge nurse will place the pink copy under the Social Services tab in the resident's chart. The white copy will be given to Social Services to follow up and obtain a signature from the resident and will be given to the billing department following the signature…
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 · D2024-08-21 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 timely transmission of a Resident Assessment Information (RAI)/Minimum Data Set (MDS) assessment for 1 Resident (R) (R34) of 14 sampled residents. R34's Quarterly MDS assessment was completed on 6/13/24. The assessment was electronically submitted on 8/21/24 which was 55 days late and not within the 14-day required timeframe. Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.1, dated October 2023, indicates: All Medicare and/or Medicaid-certified nursing homes must complete and transmit required MDS records to the Centers for Medicare and Medicaid Services' (CMS') Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. Required MDS records include Admission, Quarterly, Annual, Discharge Assessments, Death, and Entry Tracking records .Omnibus Budge Reconciliation Act (OBRA) regulations require nursing homes that are Medicare…
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 before2024-01-17 · 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 ensure an investigation regarding potential misappropriation of property for 1 Resident (R) (R2) of 1 resident contained documentation that indicated a thorough investigation was completed. On 9/30/23, the facility submitted an initial report to the State Agency (SA) regarding potential misappropriation of tramadol (a controlled substance and narcotic medication used to treat moderate to severe pain) prescribed to R2. On 10/6/23, the facility submitted the findings of their investigation. The investigation did not contain documentation that indicated a thorough investigation was completed. Findings include: The facility's Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, with a review date of 7/2023, indicated: All reports of resident abuse, neglect and injuries of unknown source shall be immediately and thoroughly investigated 9. The results of the investigation will be reduced to written form. 10. The investigator…
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 before2023-09-14 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent or contain the transmission of communicable diseases and infection, including COVID-19. This had the potential to affect all 63 residents residing in the facility. The facility did not ensure staff performed proper hand hygiene during the provision of cares for 4 Residents (R) (R7, R8, R11, and R13) of 4 residents. The facility did not ensure staff wore eye protection in rooms of residents who were on isolation precautions related to COVID-19. The facility did not ensure staff wore an N95 respirator in a resident's room who was on isolation precautions related to COVID-19. Certified Nursing Assistant (CNA)-D did not appropriately remove personal protective equipment (PPE) or complete hand hygiene when exiting the room of a resident on isolation precautions. CNA-D did not perform appropriate hand hygiene during the provision of perineal care for R7. CNA-E did not perform appropriate 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 · D2023-09-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not provide appropriate treatment and services to prevent a urinary tract infection (UTI) for 1 Resident (R) (R7) of 4 sampled residents. R7 was not provided perineal cleansing after an episode of urinary incontinence. Findings include: The facility's Perineal Care policy, revised June 2010, contains the following information: Perineal care is performed by all nursing personnel to clean the perineum and to provide comfort. It is done as a part of AM and PM care, after bathroom use for residents who require assistance, and after incontinent episodes. 7. Use toilet tissue to remove gross soiling. Discard in trash bag immediately. Perform hand hygiene and put on clean gloves. 8. Wash skin with soap and water or peri-wash: Wash front to back with 3 motions (middle and each side of peri area) using a clean section of cloth for each pass. Gently dry clean buttocks area, front to back, using a clean section of cloth for each pass. Dry gently. 1.…
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 before2023-06-07 · 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
Based on observation, staff interview, and record review, the facility did not ensure food was served under sanitary conditions. This had the potential to affect multiple residents. Items located in the kitchen and kitchenettes were not properly dated, were past the manufacturer's best-by date and did not contain resident names. Findings include: On 6/7/23 at 7:40 AM, Regional Dietary Manager (RDM)-F verified the facility followed the Federal Food Code. The FDA food code 2017 documented at 3-501.17, Ready to Eat, Time Temperature Control for Safety Food Date Marking ready-to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees F (Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The FDA Food Code 2017 at 3-501.17 (B) indicated: Commercially processed food open and hold cold .refrigerated, ready to eat time/temperature…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-07 · 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 notify a physician of a change in condition for 1 Resident (R) (R60) of 21 sampled residents. R60's physician was not notified of R60's change of condition on [DATE]. Findings include: The facility's Change of Condition-Notification and Documentation policy, revised [DATE], contained the following information: The resident's physician and family will be notified of changes in the resident's physical, mental, and psychological status, and these changes will be reported to the multidisciplinary care plan team, so that appropriate changes in the plan of care can be implemented .Per CFR 483.10, a change of condition is defined as an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical…
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 · D2023-06-07 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview, and record review, the facility did not ensure 1 Resident (R) (R45) of 18 sampled residents met the PASRR (Pre-admission Screen and Resident Review) requirements. R45's Level I PASRR screen was marked yes for a 30-day exemption; however, R45 remained in the facility beyond the 30 days without a Level II PASRR screen. Findings include: The facility's Resident Assessment-Coordination with PASRR Program policy, revised February 2023, contained the following information: 1. All individuals with a mental disorder or intellectual disability who apply for admission to this facility will be screened in accordance with the State's Medicaid rules for screening .4. Recommendations, such as any specialized services, from a PASRR Level II determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. R45's medical record indicated R45 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder,…
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 · D2023-06-07 · 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 staff interview, and record review, the facility did not obtain weights as part of nutritional monitoring for 1 Resident (R) (R50) of 1 resident reviewed for tube feeding. R50's admission orders included an order for daily weights. The facility's policy was to obtain weekly weights. Staff obtained two weights for R50 from 5/12/23 through 6/7/23. Findings include: The facility's Nutrition At Risk Assessment policy, revised 8/08, contained the following information: The Director of Nursing (DON) or designee and the Dietician shall meet weekly or monthly as appropriate to review the residents currently on the NAR (Nutrition at Risk) (list) and any other residents identified as having had a nutritional change. Nutritional change includes, but are not limited to: a. Significant weight loss . The policy did not mention how often weights were to be obtained. On 6/5/23, Surveyor reviewed R50's medical record. R50 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (stroke),…
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NORTHLAND LUTHERAN RETIREMENT COMM | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 11/15/1988 |
| LANCOUR, DARRELL | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2015 |
| ROWELL, CHARLES | Individual | W-2 MANAGING EMPLOYEE | — | since 12/31/2021 |
CMS files one row per role, so the 6 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $265K 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 525476. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-10, 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.