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Milwaukee Health and Rehab

3216 W Highland Blvd, Milwaukee, WI 53208 · For profit - Limited Liability company · 95 certified beds · (414) 344-6515 Medicare & Medicaid certified

Call the home — (414) 344-6515 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 Jul 2025
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
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
  • its payroll-based staffing rating is low (2/5)

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

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

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Urgent care / clinic
950 N 35th St · (414) 431-1235 · Call to confirm hours
Pharmacy
Walgreens0.4 mi
3522 W Wisconsin Ave · (414) 342-4446 · Call to confirm hours
Grocery
901 N 27th St · (414) 344-4626 · Call to confirm hours
Park
· Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 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 2 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 increased10.3%16.1%15.4%better
Long-stay residents who lose too much weight4.9%5.1%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%2.1%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.9%2.7%2.0%better
Long-stay residents with depressive symptoms5.3%5.7%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.8%3.3%3.3%better
Long-stay residents whose ability to walk worsened4.5%18.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.2%16.9%18.9%better
Long-stay residents given the seasonal flu vaccine75.0%95.0%95.3%worse
Long-stay residents with pressure ulcers3.5%5.0%4.7%better
Long-stay residents with worsening bladder/bowel control18.1%24.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table14.5%15.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine31.1%82.2%79.4%worse

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.

11.0%U.S. median 10.7%
Went back to hospital
0.20U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 7.0–16.510.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 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

0.47
RN hours/ resident / day
0.93
LPN hours/ resident / day
1.59
Aide hours/ resident / day
3.00
Total nurse hours/ resident / day
0.23
RN hoursweekends
52.2%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 95 beds and averages 60.2 residents a day — about 63% occupied, or roughly 35 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 3.00 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.59 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.74 hrs/resident/day on weekends vs 3.10 on weekdays — 12% thinner on weekends. RN hours go from 0.57 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% 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

3
deficiencies at the latest standard inspection (2025-12-08)
3
at the previous standard inspection (2024-07-24)

Deficiencies are unchanged from the previous inspection. 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 · D2025-12-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 (R11) of 14 residents reviewed for Activities for Daily Living (ADL).*R11 was observed to be double briefed during incontinence cares.Findings:The Facility provided policy, titled Incontinence with no last review/revised date, indicates . 4. Residents that are incontinent of bladder will receive appropriate treatment to prevent infections and to restore continence to the extent possible. R11 was admitted to the facility on [DATE], with diagnoses including Dementia (an umbrella term for severe cognitive decline (memory, thinking, reasoning) that impairs daily life), Alzheimer's Disease (a progressive brain disorder, the most common cause of dementia, characterized by memory loss, impaired thinking, and difficulty with daily activities) and retention of urine (the inability to fully empty…

    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 · Dcited before2025-12-08 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility did not ensure 1 (R45) of 1 resident receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.*R45 was observed to not have a splint in place for R45's right hand.Findings include:The facility's policy titled, Use of Assistive Devices with no reviewed/revised date, indicates the following, . 2. The use of assistive devices will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care. 3. The facility will provide assistive devices for residents who need them. Nursing, dietary, social services, and therapy departments will work together to ensure availability of devices, such as for ordering and/or replacement.R45's diagnoses includes Hemiplegia (affecting one side of the body, severe weakness or complete loss of movement, sensation, and coordination on the affected side.) affecting right, dominate side and contracture (a permanent tightening and shortening of muscles, tendons, skin, or other tissues, causing…

    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 · Dcited before2025-07-10 · 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 interviews and record review, the facility did not ensure allegations of verbal abuse were immediately reported to the Administrator. This was observed with 1 (R1) of 1 resident reviewed for allegations of verbal abuse.On 6/29/2025 staff and R1 heard Registered Nurse (RN)-D call R1 a dizzy bitch around 9:30pm. The verbal abuse was observed by other staff but not reported to Nursing Home Administrator (NHA)-A until the following morning on 6/30/2025. RN-D continued to finish RN-D's shift which ended at 11:00pm. Findings include:The facility policy titled ABUSE POLICY no initiation or revision date documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this…

    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 · D2025-07-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the safety and supervision of 1 (R1) of 1 resident reviewed for supervision and accidents. On 6/28/2025 while sitting outside R1 asked another resident to push them to the store. The other resident began to push R1's wheelchair to the store. The facility did not re access R1 for elopement risk, ability to leave the facility unsupervised, or initiate a care plan to prevent future incidents from happening. Findings include:The facility policy titled Elopements and Wandering Residents reviewed/revised 5/8/2025 documents: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: . 3. The facility shall establish and utilize a systemic approach to monitoring and managing…

    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 · D2024-10-31 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to ensure hospital physicians orders were implemented for one of one resident (Resident (R) 1) reviewed for implementation of physician orders out of a survey sample of nine. Specifically, the facility failed to obtain a laboratory blood test for vitamin D (to determine low bone density, fatigue, bone pain). In addition, the facility failed to coordinate services with R1's responsible party to ensure that one medical appointment was to be scheduled after the resident was discharged by the hospital and readmitted back to the facility. This failure had the potential for the resident to not receive appropriate continuum of care. (Cross Reference F690 and F692) Findings include: Review of a facility policy titled Physician Orders, dated 01/31/18, indicated .To provide general guidelines when receiving, entering, and confirming physician or prescriber's order. The policy failed to address following physician orders from another…

    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 · Dcited before2024-10-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 record review, interviews, and review of the facility's policy, the facility failed to ensure one of nine sampled residents (Resident (R)1) had a bowel program implemented. This deficient practice may result in bloating, pain, and general discomfort. Findings include: Review of a facility policy titled, Bowel Elimination Protocol, dated 09/2024, indicated, .CNAs [Certified Nurse Aides] are responsible for documenting bowel movements and for asking alert residents who toilet themselves about their elimination each shift . Residents who have had no BM (bowel movement) for 72 hours will be considered for pharmacological intervention or increased non-pharmacological intervention. Additional information related to elimination may need to be gathered . e.g. bowel sounds. Review of R1's electronic medical records (EMR) titled admission Record, located under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R1's EMR titled Clinical Physician Orders, located under 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 · Dcited before2024-10-31 · 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 record review, observation, staff interviews, and facility policy review, the facility failed to assess nutritional status after a significant weight gain and loss and failed to take corrective action after the facility determined the weight gain and loss was an error for one of one resident (Resident (R) 1) reviewed for nutrition in a total sample of nine residents. Findings include: Review of a facility policy titled, Weight Monitoring Program, dated 09/29/23 indicated . Each resident's weight will be monitored consistently and closely by the interdisciplinary team. All residents with patterned or significant weight changes will be assessed by the facility's interdisciplinary team as indicated. Interventions to address nutritional issues will be initiated and incorporated into the resident's care plan and re-evaluated on a timely and periodic basis . The IDT is responsible for reviewing weights, notifying appropriate disciplines of significant changes, initiating corrective actions and completing…

    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 · F2024-08-19 · tag F0880 — failed to prevent and control infections — widespread
    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 interviews and record review, the facility did not implement their water management plan based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of waterborne pathogens. This deficient practice has the potential to affect all 64 residents. The facility's water heating system stopped working on 8/10/2024. The facility was without hot water from 8/10/2024 - 8/15/2024. ~The facility did not call a contracted company to come to the facility to assess the concern until 8/12/2024 and the contracted company did not get to the facility until 8/14/2024 to assess and fix the concern. ~Water temperatures and testing were not completed during the time the water heater system was not working (8/10/2024 - 8/14/2024) and the facility did not take corrective actions when control limits were not met. Findings include: The 7/6/18 revised CMS (Centers for Medicaid and Medicare Services) Quality, Safety and Oversight Letter 17-30 titled,…

    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 · F2024-07-24 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility did not ensure sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficient practice has the potential to affect all 66 residents residing in the facility at the time of this survey. *On 7/23/24 at 11:07 AM, Surveyors conducted the resident council interview task. R58 shared with surveyors that night shift at the facility is like a ghost town due to lack of staff. R58 shared that they have had their call light unanswered for almost an hour at times. R58 told Surveyor that they have been afraid at times that they would be incontinent of bladder due to waiting for toileting assistance but were able to hold their bladder. The facility triggered for low weekend staffing for Fiscal Year Quarter 2 (January 1st 2024-March 31st 2024.) Findings include: On 7/23/24 at 8:30 AM, Surveyor reviewed facility's CASPER PBJ (Payroll Based Journal) report. Surveyor noted the facility triggered for low weekend staffing for Fiscal Year…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-24 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility did not ensure residents had a safe, clean, comfortable and homelike environment for 1 of 2 shower rooms observed in the facility. On 7/23/24, at 10:55 AM, Surveyor observed the 2nd floor shower room had yellow tape across the door and a sign that read out of order. All facility residents that required showers had to use the 3rd floor shower room which was not maintained in a hygienic manner. Findings include: The facility did not have a policy and procedure specific to cleaning of shower rooms. Surveyor was provided a sheet of paper titled Daily Room Cleaning checklist which addressed cleaning of resident rooms only. On 7/23/24, at 10:55 AM, Surveyor observed the 2nd floor shower room had yellow tape across the door and a sign that read out of order. On 7/23/24, at 11:00 AM, Certified Nursing Assistant (CNA)-H showed Surveyor the shower room on the 3rd floor. CNA-H confirmed the 3rd floor shower room is working and staff is using it for residents' showers because the 2nd floor shower room is broken. Surveyor observed the following in…

    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
Show the remaining 11 citations
  • Potential for harm · Dcited before2024-07-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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, interview, and record review the facility did not ensure that residents who enter the facility with an indwelling catheter are assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary and residents received appropriate treatment and services to restore continence to the extent possible for 1 of 2 (R55) residents reviewed for catheters. R55 had Urologist orders that were not followed. Findings include: R55 admitted to the facility on [DATE] and has diagnoses that include Transverse Myelitis in Demyelinating Disease of Central Nervous System, Neuromuscular Dysfunction of Bladder and Paraplegia. R55's admission Minimum Data Set (MDS) dated [DATE] documents: Indwelling catheter (including suprapubic catheter and nephrostomy tube) - Yes. The Care Area Assessment (CAA) worksheet documents (in part) . Triggered Indwelling Catheter: Current Dx (diagnosis) of acute transverse myelitis in demyelinating 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-18 · 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 interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by reporting 3 of 5 allegations of abuse (slap in face, kicked, and slapped) to law enforcement and immediately reporting 5 of 5 allegations of abuse to the State Survey Agency for 1 of 5 (R1) residents reviewed for abuse. * On 10/8/2023, R1 and R1's family member made an allegation of R1 being slapped on the face. Registered Nurse (RN-C) did not immediately notify the Administrator of this allegation of abuse. This allegation of abuse was not reported to the State Survey Agency until 10/9/2023. This allegation of abuse should have been reported to the State Survey Agency no later than 2 hours after the allegation was made. Law Enforcement was not contacted immediately after allegation of R1 being slapped. * On 10/10/2023, an allegation was made that R1 was kicked because of a bruise on R1's leg and slapped on…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-18 · 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 interviews and record review the facility did not ensure allegations involving abuse were thoroughly investigated for 1 (R1) or 5 residents reviewed for abuse. On 10/12/2023 Law Enforcement arrived at the facility due to the hospital reporting potential abuse to R1 upon arrival to the emergency room with bruising to R1's eye, sternum, and leg. The abuse allegation was not in itself investigated by the facility but instead was mentioned within an investigation pertaining to a different allegation made on 10/8/23 regarding R1 being slapped. There was no staff interviews pertaining to the R1 having been identified on 10/12/23 with bruising of unknown orgin to the right eye, sternum, and R leg upon arrival to the hospital. Findings include: The facility policy, entitled Abuse Policy, with no implementation date, states: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment of residents. This facility prohibits abuse,…

    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 before2023-09-21 · 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 interview, record review, and facility policy review, the facility failed to ensure timely reporting of an allegation of verbal abuse to facility administration related to one (Resident (R) 15) of 17 residents reviewed in the sample. Findings include: Review of the facility's undated policy titled, Abuse Policy indicated, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents; and Internal Reporting Requirements: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator, immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in 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 · E2023-04-13 · 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 interview and record review, the facility did not ensure 5 (R26, R47, R33, R17, and R48) of 5 residents reviewed that required hospitalizations were given a written reason for transfer to the hospital. Before being transferred to the hospital, the facility did not notify the resident and/or the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility did not record the reasons for the transfer or discharge in the resident's medical record. R33, R17, R26, R47 and R48 and/or their resident representative did not receive written notice of the reason for transfer prior to their transfer to the hospital. Findings include: R33 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia with Behaviors, Heart Failure, Chronic Kidney Disease, Unspecified Psychosis and Muscle Weakness. The medical record indicated R33 was transferred to the hospital 2/12/23 due to a change in condition.…

    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 · E2023-04-13 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Surveyor conducted a review of R26's medical record on 04/11/23. The medical record indicated R26 was transferred to the hospital on 4/5/23. R26's medical record did not include documentation that a written notice of the bed hold policy had been given to the resident and/or representative for the hospitalization. On 4/12/23, at 10:30 AM, the Corporate Consultant-D was interviewed and indicated a bed hold notice was not completed for R26 on 3/29/23 and should have been. The above findings were shared with the Administrator and Director of Nursing on 4/12/23 at 3:00 PM at the daily exit meeting. Additional information was requested if available. None was provided. 4. On 04/11/23, Surveyor reviewed R47's medical record and it indicated R47 was transferred to the hospital on [DATE]. R47's medical record did not include documentation that a written notice of the bed hold policy had been given to the resident and/or representative for the hospitalization. On 4/12/23. at 10:30 AM, the Corporate Consultant-D 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-13 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews the facility did not ensure each resident received food that is palatable and at an appetizing temperature for 4 of 4 (R28, R36, R48 and R53) R48 reported they receive cold eggs with breakfast. Resident Council participants (R28, R36 and R53) reported room meal trays are served cold. Findings Include: R48 admitted to the facility on [DATE] and has a Brief Interview for Mental Status (dated 3/27/23) of 13, indicating no cognitive impairment. On 4/10/23, at 9:43 AM, R48 reported she eats breakfast in her room and sometimes eats in the dining room for other meals. R48 reported she eats eggs every day and they are always cold. Surveyor asked if staff will reheat food. R48 stated: I suppose so, but they have a lot of people, it would take too long. On 4/12/23 at 11:00 AM during the resident council meeting with facility residents, R28, R36 and R53 reported food is cold, concern is realted to meals being delivered to floor/units and then it cools down before delivered. The Facility…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-13 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for 1 (R9) of 2 residents reviewed for range of motion. R9 was observed not wearing left hand palm splint for three days of survey. Findings include: R9 admitted to the facility on [DATE] and has diagnoses that include major depressive disorder, hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side, vascular dementia and end stage renal disease. R9's Quarterly Minimum Data Set (MDS) dated [DATE] section G0400-Functional Limitation in Range of Motion documents: Upper extremity (shoulder, elbow, wrist, hand) Impairment on one side. R9's care plan focus area revised 5/1/21 documents; The resident has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) Dementia, Hemiplegia, Limited Mobility. Interventions include: Left hand palm splint for 8-12 hours 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-13 · 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 record record review and staff interviews, the facility did not ensure that 1 (R8) out of 1 resident 's reviewed with significant weight loss were provided with nutritional care and services to maintain acceptable parameters of nutritional status based on a comprehensive assessment. On 12/9/22, R8 weighed 212 pounds. On 1/6/23, R8 weighed 198 pounds, which was a significant weight loss of 14 pounds in 1 month. On 2/23/23, R8 was documented to weigh 179. This further weight loss of 19 pounds is a significant weight loss. As of 4/13/23, R8 weighed 178 pounds and did not have any further comprehensive assessment of their significant weight loss. The facility did not revise the plan of care to identify if this weight loss was desirable or physician prescribed or identify additional interventions to help R8 maintain weight if the weight loss was not desired. R8 experienced a severe weight loss of 16.04% over 4 months. This is evidenced by: Review of facility policy titled, Weight Monitoring Program, revised…

    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 · D2023-04-13 · 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 record review and interview, the facility did not offer the influenza and/or pneumococcal immunizations for 3 (R10, R15 and R29) of 5 residents reviewed for immunizations. * R10 was not offered the pneumococcal immunization on admission to the facility and the facility did not document if the immunizations were offered and declined. * R15 was not offered the influenza immunization on admission to the facility and the facility did not document if the immunizations were offered and declined. * R29 was not offered the Prevnar 13 immunization on admission to the facility and the facility did not document if the immunizations were offered and declined. Findings include: The facility policy and procedure entitled Influenza (Flu) Vaccination of Residents, Staff, and Volunteers Guideline and Procedure dated 10/10/2006 states: Administration Procedure: A. Current and newly admitted residents, all staff and volunteers will be offered the influenza vaccine from October of each year through the end of March 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-12-08 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 56 residents residing in the facility.Staffing information for Quarter 2 (January 1 - March 31) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS. Findings include: The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, indicates: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care staffing and census data…

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

    Administration Deficiencies · Deficient, Provider has date of correction

“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.

Part of a chain

This home belongs to AVINA HEALTHCARE — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.2+1.8 vs chain
Health inspection 4 of 52.1+1.9 vs chain
Staffing 2 of 51.9+0.1 vs chain
Quality measures 4 of 53.3+0.7 vs chain
The other 8 homes this chain runs (chain average 2.2★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
BRANDMAN, GITTELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 09/01/2014
BRANDMAN, JOSEPHIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2014
TOPPER, AARONIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2014

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.

$6.3M
Net patient revenuemost recent cost report
-5.0%
Operating marginrevenue minus expenses
$669K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 95%Medicare 2%Other / private 4%

About 95% 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 $669K paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$291per resident / day
operating cost
$8,839per month
≈ monthly operating cost
$277per 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 525417. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-08, 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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