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Oakridge Gardens Nur Ctr, Inc

1700 Midway Rd, Menasha, WI 54952 · For profit - Limited Liability company · 106 certified beds · (920) 739-0111 Medicare & Medicaid certified

Call the home — (920) 739-0111 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Feb 2025Behavioral-health or dementia-care citation — no harm found (F0744)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • 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)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (21) — 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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1398 S Oneida St · (920) 666-7605 · Call to confirm hours
Pharmacy
Shopko0.7 mi
1578 Appleton Rd · (920) 722-1895 · Call to confirm hours
Grocery
Menasha0.3 mi
1355 Oneida Street
Park
1651 Sandys Ln · (920) 720-7108 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.9%16.1%15.4%better
Long-stay residents who lose too much weight0.0%5.1%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.8%2.1%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.5%2.7%2.0%better
Long-stay residents with depressive symptoms9.3%5.7%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.6%3.3%3.3%better
Long-stay residents whose ability to walk worsened20.6%18.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication12.1%16.9%18.9%better
Long-stay residents given the seasonal flu vaccine96.2%95.0%95.3%typical
Long-stay residents with pressure ulcers1.2%5.0%4.7%better
Long-stay residents with worsening bladder/bowel control32.0%24.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table15.6%15.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.3%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine95.8%82.2%79.4%better
Short-stay residents rehospitalized after admission28.7%23.1%22.6%worse
Short-stay residents with an outpatient ER visit11.6%15.5%12.0%typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

56.9% 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 144 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.9%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
21.9%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 21.9% 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 41 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 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.9%CMS range 49.8–65.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.1–13.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge21.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge31.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge12.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 4.1–13.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.731.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.90
RN hours/ resident / day
1.28
LPN hours/ resident / day
3.28
Aide hours/ resident / day
5.46
Total nurse hours/ resident / day
0.39
RN hoursweekends
50.9%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 106 beds and averages 60.9 residents a day — about 57% occupied, or roughly 45 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 5.46 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.28 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.71 hrs/resident/day on weekends vs 5.76 on weekdays — 18% thinner on weekends. RN hours go from 1.11 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% 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

8
deficiencies at the latest standard inspection (2025-05-14)
6
at the previous standard inspection (2024-04-03)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · F2025-05-14 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    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 designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, had a national certification for food service management and safety from a national certifying body, or who had an associates or higher level degree in food service management or hospitality. This practice had the potential to affect all 66 residents residing in the facility. Dietary Manager (DM)-F was not enrolled in an approved Dietary Manager training course. Findings include: On 5/12/25 at 8:34 AM, Surveyor interviewed [NAME] (CK)-E who indicated Dietary Manager (DM)-F oversaw the kitchen but was on vacation. CK-E indicated Registered Dietitian (RD)-G was at the facility once weekly on Wednesdays. Surveyor requested DM-F's certification and was provided with a copy of a ServSafe Food Protection Manager Certification that was completed on 2/18/22 but is not an approved Dietary Manager course. On 5/13/25, Surveyor requested further certification such as a Dietary Manager 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-14 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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 medications for 3 residents (R) (R270, R62, and R57) in 3 of 6 medication carts were labeled and/or dated appropriately and that expired medical supplies were removed from storage. In addition, the facility did not ensure expired supplies were removed from storage in 2 of 4 medication storage areas. This practice had the potential to affect more than 4 of the 66 residents residing in the facility. Medication carts contained open, unlabeled and undated inhalers, eye drops, and nasal sprays and expired medical supplies. Medication storage areas contained expired items. Findings include: The facility's Specific Medication Administration Procedures IIB1: Administration Procedures for all Medications, revised 1/2018, indicates: .D. Check expiration date on package/container . On [DATE] at 11:05 AM, Surveyor observed the [NAME] Rehab medication cart and noted the following: ~ One Tegaderm film 1622W dressing with an expiration 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 more than 4 of the 66 residents residing in the facility. The facility did not ensure food was dated/stored in a manner to ensure food safety. Findings include: Food Labeling/Storage: The facility's Food Receiving and Storage policy, dated 4/4/25, indicates: Food shall be received and stored in a manner that complies with safe food handling practices .Dry Storage: .4. Dry foods that are stored in bins and removed from the original packaging, labeled, and dated (use-by date) .Refrigerated/Frozen Storage: 1. All foods in the refrigerator or freezer is covered, labeled, and dated (use-by date). The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food (TCS), Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 66 residents residing in the facility. Staff line lists did not contain last symptom dates or times and/or return to work dates for 14 staff. In addition, the facility allowed 7 staff with gastrointestinal (GI) illness symptoms to return to work earlier than recommended per the facility's policy and the Centers for Disease Control and Prevention (CDC) guidelines. The facility also allowed 1 staff who tested positive for influenza to return to work earlier than recommended per the facility's policy. R172 was on contact precautions. On 5/12/25, Physical Therapist (PT)-H provided care in R172's room without a gown and gloves. Staff did not sanitize the vitals machine after use for R33. The facility did not ensure R268 was…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 residents (R) (R50 and R57) of 23 sampled residents had the appropriate signatures on their Emergency Care Do Not Resuscitate Order (DNR) forms (Department of Health Services (DHS) Division of Public Health F-44763) thus rendering the DNR orders invalid. R50 had an activated Power of Attorney for Healthcare (POAHC). R50's DNR form was not signed by R50 or R50's POAHC. R57's DNR form was not signed by R57 or R57's POAHC. Findings include: Chapter 155.05(2) Wisconsin Statute indicates: .(2) Unless otherwise specified in the power of attorney for healthcare instrument, an individual's power of attorney for healthcare takes effect upon a finding of incapacity by 2 physicians, as defined in s. 448.01 (5), or one physician and one licensed psychologist as defined in s. 445.01 (4) who personally examine the principal and sign a statement specifying that the principal has incapacity. The statute also indicates: A copy of the statement, if made,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · tag F0640 — isolated
    Encode 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 the required Minimum Data Set (MDS) assessment data was transmitted timely for 3 residents (R) (R16, R175, and R174) of 3 sampled residents. R16 and R175s' Discharge MDS assessments were not completed or submitted. R174's Discharge MDS assessment was not submitted. Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.1, dated 10/2023, indicates: All Medicare and/or Medicaid-certified nursing homes must complete and transmit required Minimum Data Set (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 .Comprehensive MDS assessments include: Admission, Annual, Significant Change .The MDS completion date must be no later than 14 days after the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not follow the plan of care during a transfer for 1 resident (R) (R45) of 2 sampled residents. R45 had a history of falls. R45's plan of care contained an intervention to use a gait belt and a 2-wheeled walker during transfers. On 5/12/25, staff transferred R45 without a gait belt or 2-wheeled walker. Findings include: The facility's Safe Program Lifting and Movement of Residents policy, revised 7/2017, indicates: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .2. Manual lifting of residents shall be eliminated when feasible .4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. On 5/12/25, Surveyor reviewed R45's medical record. R45 was admitted to the facility on [DATE] and had diagnoses including unspecified…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and record review, the facility did not ensure the medication error rate was below 5%. During medication administration, Surveyor observed 4 errors out of 27 opportunities which resulted in an error rate of 14.81%. This affected 3 residents (R) (R36, R172, and R33) of 5 residents observed during medication administration Staff did not ensure intravenous (IV) medications were administered within the scheduled time frame for R36 and R172. Staff did not ensure R33's blood pressure was within the ordered parameters prior to administering medication. Findings include: The facility's Specific Medication Administration Procedures IIB2: Oral Medication Administration policy, revised 1/2018, indicates: .Review and confirm medication orders for each individual resident on the Medication Administration Record (MAR) prior to administering medications to each resident. Review Medication Administration Record for any test or vital signs that need to be determined prior to preparing the medications . The facility's Specific Medication Administration…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-07 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not thoroughly investigate an allegation of abuse for 2 residents (R) (R2 and R1) of 2 sampled residents. R2 reported an allegation of physical abuse on 1/19/25 that involved Certified Nursing Assistant (CNA)-E. The facility did not ensure CNA-E was removed from or supervised during resident care pending the results of the investigation. R1 reported to a nurse on 11/29/24 that R1 was recently raped by an unknown male staff. The facility did not thoroughly investigate the allegation of sexual abuse. Findings include: The facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, dated 9/3/24, indicates: Investigating Allegations: 1. All allegations are thoroughly investigated .7. The individual conducting the investigation at a minimum: a. Reviews the documentation and evidence. b. Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-04-03 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, 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 73 of 73 residents residing in the facility. Staff did not date items with open dates and received dates. Staff did not ensure food was stored in a sanitary manner. Staff did not wash hands when moving from dirty to clean activities. Staff did not wait two minutes to take microwave reheated food temperatures to ensure food was heated evenly. In addition, staff did not ensure microwaved foods reached the food safety temperature prior to serving. Findings include: Undated Items: The Food and Drug Administration (FDA) Food Code 2022 documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition (A): A food specified in 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A) except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2024-04-03 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 Resident (R) (R50) of 2 residents. R50 was observed laying across another resident in their bed without clothes on. The potential allegation of abuse was not reported to the State Agency (SA) or local law enforcement. Findings include: The facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, with a revised date of September 2023, indicates: 1. If resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and/or designee and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. the state…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-03 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not thoroughly investigate a potential allegation of abuse for 1 Resident (R) (R50) of 2 residents. R50 was observed laying across another resident in their bed without clothes on. Facility administration was not aware the incident occurred and a thorough investigation was not completed. Findings include: The facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, with a revised date of September 2023, indicates: Investigating Allegations: 1. All allegations are thoroughly investigated. 7. The individual conducting the investigation at a minimum: a. Reviews the documentation and evidence. b. Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident. c. Observes the alleged victim, including his or her interactions with staff and other residents. d. Interviews the person reporting the incident. e. Interviews any witnesses to…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-03 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure consistent communication for 1 Resident (R) (R24) of 1 resident who received dialysis services. The facility did not provide R24 with a dialysis communication binder prior to routine dialysis appointments and did not have evidence of communication between the facility and the dialysis center on R24's dialysis days. Findings include: The facility's Care of Hemodialysis policy, with a revision date of January 2024, indicates: Purpose: To ensure the needs of the resident receiving hemodialysis are met by both the facility and the dialysis center. Residents receiving hemodialysis are transported routinely out of the facility. Communication is essential for continuity of care. Procedure: -Facility will provide ongoing assessment of the resident's condition and will monitor for complications before and after each dialysis treatment received at a certified dialysis facility. -Facility will have ongoing communication and collaboration…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-03 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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) (R34) of 3 residents with a diagnosis of dementia received the appropriate care and services to attain or maintain their highest practicable well being. R34 had a diagnosis of dementia and exhibited physically and verbally aggressive behavior. The facility did not revise R34's plan of care in an attempt to provide effective dementia treatment and behavioral interventions to enhance R34's quality of life. Findings include: On 4/2/24, Surveyor reviewed R34's medical record. R34 had a diagnosis of dementia, moderate with agitation. R34's most recent Quarterly MDS (Minimum Data Set) assessment, dated 3/26/24, contained a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R34 had severe cognitive impairment. R34 had an activated power of attorney (POA). R34 had an activity of daily living (ADL) self-care performance deficit related to aggressive behavior and Alzheimer's disease care plan, dated 2/25/24. The care plan indicated R34 required the assistance of one staff with the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-29 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 proper foot care was provided for 1 Resident (R) (R1) of 5 residents reviewed for appointment accommodations. On 4/17/23, Doctor of Podiatric Medicine (DPM)-E recommended R1 return for a follow-up appointment in two weeks to discuss the next steps for amputation of R1's toes. A follow-up appointment was not scheduled until 6/1/23 and R1 did not see DPM-E until 6/7/23. Findings include: R1 was admitted to the facility on [DATE] with diagnoses including hypothermia of bilateral hands and feet, rhabdomyolysis (breakdown of skeletal muscle), acute kidney injury (AKI), and diabetes mellitus (DM) type 2. R1's Minimum Data Set (MDS) assessments, dated 3/23/23 and 6/23/23, contained Brief Interview for Mental Status (BIMS) scores of 14 out of 15 which indicated R1 had intact cognition. On 8/31/23, Surveyor reviewed R1's medical record and noted the following: On 4/17/23, R1 was seen by DPM-E who discussed amputation of R1's left foot 5th digit 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-08 · tag F0644 — isolated
    Coordinate 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 interview and record review, the facility did not ensure 1 Resident (R) (R25) of 7 residents reviewed for Preadmission Screen and Resident Review (PASARR) had an updated Level I screen or a Level II referral completed when R25 was diagnosed with major depressive disorder and prescribed psychotropic medication (medication that affects a person's mental state). On 6/10/22, R25's provider prescribed fluoxetine (an antidepressant medication). On 9/8/22, R25's provider also prescribed lorazepam (an antianxiety medication). On 10/12/22, a diagnosis of major depressive disorder was added to R25's diagnoses list. A PASARR Level I screen and a Level II referral were not completed. Findings include: The facility's Behavioral Assessment, Intervention and Monitoring policy, revised in March of 2019, contained the following information: Assessment: 1. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-08 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 ensure 3 Residents (R) (R12, R44 and R7) of 6 residents reviewed for nutrition and weight loss received the necessary care and services to meet nutritional goals and prevent continued weight loss. R44 had a 15 pound or 11.56% unintended weight loss within three months. The facility did not update the provider regarding R44's unintended weight loss. In addition, the dietician's recommendations for a dietary supplement, appetite stimulant and to weigh R44 were not reviewed or implemented by the facility. R12 had a 9 pound or 5.49% unintended weight loss within one week. The facility did not monitor R12's variation of weight or update the provider following the unintended weight loss. In addition, the dietician's recommendation for a dietary supplement was not reviewed or implemented by the facility. R7 had a physician order for daily weights. R7's weight was not obtained daily. In addition, R7's weight changes were not reported to the provider 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-08 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 Residents (R) (R54 and R163) of 8 sampled residents reviewed for influenza vaccination were offered the vaccine. In addition, the facility did not ensure 2 Residents (R35 and R163) of 8 sampled residents reviewed for vaccinations were offered the Prevnar (PCV) 13 vaccine as indicated. R54 was admitted to the facility on [DATE] and was not offered the influenza vaccine. R35 was admitted to the facility on [DATE] and was not offered the PCV13 vaccine. R163 was admitted to the facility on [DATE] and was not offered the influenza or PCV13 vaccines. Findings include: The facility's Influenza Vaccine policy contained the following information: 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents .6. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record. The facility's Pneumococcal Vaccine policy contained…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-08 · tag F0887 — isolated
    Educate 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 3 Residents (R) (R54, R163, and R260) of 8 residents reviewed for vaccinations were offered or received the COVID-19 vaccine. R54, R163, and R260's medical records did not include documentation that indicated the residents received or declined the COVID-19 vaccine. Findings include: The facility's COVID-19 Immunization policy contained the following information: Rationale: The CDC (Centers for Disease Control) and the Advisory Committee on Immunization Practices (ACIP), recommends the administration of the COVID-19 vaccine .to . residents of long-term care facilities. R54 was admitted to the facility on [DATE]. R54's medical record did not contain documentation that indicated R54 received or declined the COVID-19 vaccination. R163 was admitted to the facility on [DATE]. R163's medical record did not contain documentation that indicated R163 received or declined the COVID-19 vaccination. R260 was admitted to the facility on [DATE]. R260'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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-04-03 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    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 a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 73 residents residing in the facility. IP-J did not complete specialized training for infection prevention and control. Findings include: The facility's Infection Preventionist policy and procedure, last reviewed September 2023, indicates: Specialized Training: 1. The infection preventionist has obtained specialized IPC (infection prevention and control) training beyond initial professional training or education prior to assuming the role, including in the following topics .2. Evidence of training is provided through a certificate(s) of completion or equivalent documentation . On 4/3/24 at 2:39 PM, Surveyor interviewed IP-J who verified IP-J started as the IP in August of 2023 and did not have specialized infection control training. IP-J stated IP-J was informed about the required training on 4/2/24. On 4/3/24 at 2:57 PM, Surveyor…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-02-08 · tag F0623 — pattern
    Provide 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) (R58, R32 and R18) of 15 residents reviewed for hospitalization received the proper notice to include date 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 State Long-Term Care Ombudsman of hospital transfers for 14 Residents (R58, R10, R11, R25, R34, R47, R48, R173, R174, R175, R176, R177, R32 and R18) of 15 residents reviewed for hospitalization. R58 was transferred to the hospital on [DATE]. The facility did not did not inform R58's representative in writing or the Ombudsman of the transfer. R10 was transferred to the hospital on [DATE]. The facility did not inform the Ombudsman of the transfer. R11 was transferred to the hospital on [DATE]. The facility did not inform the Ombudsman of the transfer. R25 was transferred to the hospital on [DATE]. The facility did not inform the Ombudsman of the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
SCHANKE, MICHAELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER100%since 01/01/1998
SCHANKE, AMYIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/01/2012

CMS files one row per role, so the 6 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$11.1M
Net patient revenuemost recent cost report
-9.5%
Operating marginrevenue minus expenses
$886K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 42%Medicare 9%Other / private 49%

This home reported $886K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$506per resident / day
operating cost
$15,392per month
≈ monthly operating cost
$462per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WI

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.

Typical monthly cost in Wisconsin
$10,646/mo
Nursing home (semi-private)
$12,319/mo
Nursing home (private)
$6,540/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525463. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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