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St Ann Health and Rehabilitation Center

2020 S Muskego Ave, Milwaukee, WI 53204 · For profit - Corporation · 50 certified beds · (414) 383-2630 Medicare & Medicaid certified

Call the home — (414) 383-2630 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Nov 2023Behavioral-health or dementia-care citation — no harm found (F0740)
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 a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — 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 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1639 S 23rd St · (414) 286-8620 · Call to confirm hours
Pharmacy
Walgreens0.3 mi
2410 W Forest Home Ave · (414) 383-3414 · Call to confirm hours
Grocery
2079 S Muskego Ave · (414) 334-8635 · Call to confirm hours
Park
1601 S 23rd St · (651) 723-7378 · Typically dawn to dusk
Place of worship
2025 S Muskego Ave

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 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 2025-06 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 increased21.2%16.1%15.4%worse
Long-stay residents who lose too much weight11.8%5.1%5.4%worse
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 infection4.0%2.7%2.0%worse
Long-stay residents with depressive symptoms2.8%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 injury5.1%3.3%3.3%worse
Long-stay residents whose ability to walk worsened18.1%18.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication27.8%16.9%18.9%worse
Long-stay residents given the seasonal flu vaccine91.3%95.0%95.3%typical
Long-stay residents with pressure ulcers2.8%5.0%4.7%better
Long-stay residents with worsening bladder/bowel control22.0%24.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table13.3%15.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.7%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine60.5%82.2%79.4%worse
Short-stay residents rehospitalized after admission19.2%23.1%22.6%better
Short-stay residents with an outpatient ER visit9.1%15.5%12.0%better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

38.6% 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 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

38.6%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
25.0%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 25.0% 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 24 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 0.37 therapist hours per resident per day in 2026Q1 — more than 62% 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 SNF38.6%CMS range 26.8–54.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 7.5–16.410.7%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 discharge25.0%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 discharge16.7%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 discharge20.8%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 identified72.7%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 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 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 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 SNFs0.991.02Oct 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

0.81
RN hours/ resident / day
0.73
LPN hours/ resident / day
2.73
Aide hours/ resident / day
4.27
Total nurse hours/ resident / day
0.40
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 50 beds and averages 45.2 residents a day — about 90% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.27 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.73 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.87 hrs/resident/day on weekends vs 4.43 on weekdays — 13% thinner on weekends. RN hours go from 0.97 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

6
deficiencies at the latest standard inspection (2026-03-05)
3
at the previous standard inspection (2025-02-06)

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 · Ecited before2026-03-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 observations, interviews, record review, and policy review, the facility failed to ensure that quarterly safety evaluations accurately identified and documented the use of elopement-prevention devices, that care plans were developed for residents utilizing wander guards, and that Minimum Data Set (MDS) assessments reflected the presence of these safety devices for three of three residents (Resident (R)3, R8, and R45) reviewed for elopement. As a result of this deficient practice, staff did not recognize wander guards as a safety device to ensure all needed interventions were implemented.re respiratory equipment was stored in a sanitary manner for one of one resident (Resident (R) 15) reviewed for respiratory care out of a total sample of 17. This had the potential to expose the resident to infection. Findings include:1. Review of R3's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 05/07/25 with medical diagnoses including vascular…

    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 before2026-03-05 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 observation, policy review, record review, and interview, the facility failed to ensure that a resident was transferred in a dignified manner for one resident (Resident (R) 24) out of a total of 17 sampled residents reviewed. This failure has the potential to negatively impact a resident's dignity and psychological well-being. Findings include:Review of R24's Face Sheet, located in the Profile tab of electronic medical record (EMR), revealed R24 was admitted on [DATE] with diagnoses of legal blindness, mild cognitive impairment, major depressive disorder, muscle weakness, difficulty walking, and need assistance with personal care. Review of R24's quarterly Minimum Data Set (MDS), located in the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 03/04/26, revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated R24 had moderate cognitive impairment. The MDS also indicated R24 ambulated with a wheelchair, and she was dependent on staff…

    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 · D2026-03-05 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, record review, and the Resident Assessment Instrument (RAI) Manual review, the facility failed to ensure three of three residents (Resident (R) 3, R8, and R45) reviewed for wander guard placement had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly can lead to inaccurate federal reimbursement and inaccurate assessment and care planning for the residents.Findings include: 1. Review of R3's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 05/07/25 with medical diagnoses including vascular dementia with severe anxiety and major depressive disorder.Review of the physician's orders for R3, located in the EMR under the Orders tab, documented an order on 05/13/25, Wander Guard to Right Ankle. Check function daily. Update nurse if any malfunction.Review of R3's quarterly MDS assessment with an Assessment Reference Date (ARD) of 12/31/25, located in the EMR under the MDS tab, lacked documentation of the presence of a wander/elopement alarm.An observation…

    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 · D2026-03-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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, record review, and policy review, the facility failed to ensure a care plan was developed for one of three residents (Resident (R) 3) reviewed for wander guard placement to prevent elopement. This deficient practice increases the risk of inconsistent staff responses and elopement.Findings include:Review of R3's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 05/07/25 with medical diagnoses including vascular dementia with severe anxiety and major depressive disorder.Review of the Elopement assessment dated [DATE], located under the Evaluations tab in the EMR, documented R3 was a high risk for elopement.Review of the physician's orders for R3, located in the EMR under the Orders tab, documented an order on 05/13/25, Wander Guard to Right Ankle. Check function daily. Update nurse if any malfunction.Review of R3's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference…

    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 · D2026-03-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy review, the facility failed to ensure respiratory equipment was stored in a sanitary manner for one of one resident (Resident (R) 15) reviewed for respiratory care out of a total sample of 17. This had the potential to expose the resident to infection. Findings include:Review of R15's Face Sheet, located in the Profile tab of electronic medical record (EMR), revealed R15 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), malignant neoplasm of unspecified right bronchus or lung, and acquired absence of lung. Review of R15's Care Plan Report, located in the Care Plan tab of the EMR, revealed a focus, revised on 04/04/25, which indicated R15 had PRN (as needed) oxygen therapy due to end of life and lung cancer. A focus, revised on 04/17/25, indicated R15 had altered respiratory status or difficulty breathing due to lung cancer and COPD. Review of R15's quarterly Minimum Data Set (MDS), located in the MDS tab of the EMR…

    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 before2026-03-05 · 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, interviews, record review, and policy review, the facility failed to ensure that resident (Resident (R)13) received medications in the correct dosage and as ordered. This resulted in two medication errors out of 32 opportunities, yielding a medication error rate of 6.25%. These errors had the potential to reduce the effectiveness of the prescribed treatment due to underdosing.Findings include:1. Review of R13's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 08/26/22 and readmission date of 09/12/25 with medical diagnoses that included major depressive disorder and chronic (diastolic) congestive heart failure (CHF).Review of R13's quarterly Minimum Data Set (MDS) assessment, under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 12/11/25, revealed R13 used antidepressant and diuretic medications, and review of her drug regimen revealed no significant issues.Review of the March 2026 Medication Administration Record (MAR), located under the Orders tab of the EMR, revealed an…

    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 before2026-02-11 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 observation and interviews, the facility did not ensure each resident is treated with dignity and respect that promoted maintenance or enhancement of quality of life. This occurred for 2 (R1 and R2) of 3 Residents reviewed for dignity.*On 2/11/26, Surveyor observed Certified Nursing Assistants (CNA) C and D standing, while feeding R1 and R2 their meals. CNA-C was also observed feeding two residents interchangeably at the same time. Findings Include:The facility Meal Supervision and Assistance reviewed/revised 10/29/24 documents:Guideline:.The resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes:1.Identifying hazard(s) and risk(s)2.Evaluating and analyzing hazard(s) and risk(s)3.Implementing interventions to reduce hazard(s) and risk(s)4.Monitoring for effectiveness and modifying interventions 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-01 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and facility document review, the facility failed to ensure known resident behaviors of kicking, hitting, grabbing, rejection of care, et cetera (etc., other similar things) were addressed, to include the development and implementation of interventions, for 1 (Resident #2) of 5 sampled residents reviewed for behaviors. Findings included:An admission Record revealed the facility initially admitted Resident #2 on 04/09/2024 and most recently admitted the resident on 10/31/2024. According to the admission Record, the resident had a medical history that included diagnoses of encephalopathy (disease in which the functioning of the brain is affected); epilepsy (seizure disorder); hemiplegia (complete paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side; unspecified dementia, moderate, with other behavioral disturbance anxiety disorder; insomnia; and need for assistance with personal care. An annual Minimum Data Set (MDS), with an Assessment…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-02-06 · 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 and interview, the facility failed to store and serve food in accordance with professional standards for food service safety for 46 of 48 residents that receive food from the kitchen. * In the facility's main kitchen, observations of partially used and undated food were made in the walk-in and wall freezers/coolers. Several food items were observed in one of the facility's main kitchen wall coolers uncovered open to air and undated. * [NAME] restraints were not being utilized by a kitchen staff working in the main kitchen area. * Temperatures were not completed on all required food items prior to serving the food to residents. Findings include: The facility policy titled Food Safety Requirements, date reviewed 04/29/2024 documents: Policy Explanation and Compliance Guidelines: 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. Subsection iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its…

    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 before2025-02-06 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 interview, the facility failed to maintain 1 (R14) of 12 residents reviewed their right to personal privacy and confidentiality of his or her personal and medical records. * R14's protected health information was left on a computer screen unattended in a common area. R14's medication administration record was displayed on the computer screen in full view of residents and staff that were in and around the common area. Findings include: 1.) R14 was admitted on [DATE] with diagnosis that included Cerebral Infarction, Chronic Obstructive Pulmonary Disease (COPD), Depression and Alzheimer's Disease. R14's Quarterly Minimum Daily Set (MDS) with an assessment reference date of 12/4/24, documents a Brief Interview for Mental Status (BIMS) score of 12, indicating that R14 has moderate cognitive impairment. Section GG documents that R14 uses wheelchair for mobility. On 02/05/25, at 09:28 AM, Surveyor observed Registered Nurse (RN)-D passing medication from the medication cart. RN-D was observed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2025-02-06 · 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

    Based on interview and record review the facility did not ensure 1 (R12) of 12 residents who were reviewed for a change of condition received a comprehensive assessment. * On 10/6/24, R12 experienced a change in condition and RN (registered nurse)-H did not complete a comprehensive assessment prior to sending R12 to the hospital via ambulance. Findings include: 1.) R12 was admitted to the facility with diagnoses of atrial fibrillation, morbid obesity, hypertension and congestive heart failure. The nurses note dated 2/5/25 documents Resident initially c/o (complain of) stomach pain to CNA (certified nursing assistant) around 3am. Went into room to see resident--laying flat, and in the middle of having a bowel movement. Resident c/o stomach cramping and nausea. PRN (as needed) medication offered for GI discomfort-declined. Education provided. Water at bedside. Resident encouraged to push fluids and alter diet to prevent constipation. Basin retrieved by CNA in case of emesis. Resident then requested to see me again later during the shift, via CNA. CNA reports resident communicating at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-17 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident interview, staff interview, and record review, the facility failed to ensure menus were followed and served as posted and on the dietary tray cards. The failure placed any of the 45 facility residents receiving meals from the kitchen at risk of dissatisfaction with their meals. Findings include: During an interview on 10/17/24 at 12:40 PM, Resident (R) 6 complained that at least once a day the meal varies from what they are supposed to have. R6 pointed to a covered dish on her tray stating, That's not a chocolate peanut butter bar. The cover was lifted to reveal a confetti cake with a whipped type topping dollop. When asked what the menu tray card said, R6 showed the paper slip which showed Choc [Chocolate] Peanut Butter Bar. Review of R6's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/13/24 showed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicative of being cognitively intact. Review of the menu for 10/17/24 showed 1 [one] sq [square] Chocolate Peanut Butter Bar. During an interview…

    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 before2024-03-14 · 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, record review, and interview, the facility did not ensure adequate supervision and assistance devices were provided to prevent falls for 2 (R3 and R4) of 3 residents reviewed for accidents. * R3 did not have fall interventions in place per care plan to prevent a fall out of bed on 1/24/2024 and fall interventions were observed not to be in place to prevent future falls. * R4 was not transferred as per care plan resulting in a fall on 2/21/2024. R4's care plan indicated R4 required moderate assist of 2 staff members with the use of a sit-to-stand lift. On 2/21/2024, R4 was pivot transferred with the assist of 1 staff member instead of 2 staff members with the use of a sit-to-stand, resulting in R4 being lowered to the ground. Findings: 1. R3 was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease, peripheral vascular disease, amputation of right and left lower limbs above the knees, cerebrovascular disease, and chronic atrial fibrillation. R3's quarterly…

    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 · E2023-11-13 · 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 and interview, the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, to include the expiration date when applicable for 4 of 10 (R7, R17, R19 and R25) resident insulin's observed. * Residents' insulin, which was open and used, was not dated when opened and insulin was observed to be beyond the expiration date. Findings include: The facility policy titled: Insulin Pen which was not dated, documents (in part) . .It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. Policy Explanation and Compliance Guidelines: 1. Insulin pens contain multiple doses of insulin but are used for a single resident only. 2. Insulin pens must be clearly labeled with the residents name, physician name, date dispensed, type of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-13 · 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

    Based on observation and interview, the facility did not ensure the cleaning and disinfecting of a Glucometer which was being shared between 8 residents. The Glucometer was being disinfected with a 70% isopropyl alcohol wipe rather than with a disinfectant bleach wipe in order to kill blood bourne pathogens. *On 11/9/23 Surveyor observed RN (Registered Nurse)-G administer blood glucose testing for R40. RN-G did not clean and disinfect the facility's shared Glucometer with a disinfectant wipe which kills blood borne pathogens. This deficient practice had the potential to affect 8 residents residing on the 2nd floor who utilize . Findings include: The facility policy dated 2023, entitled, Glucometer Disinfection reads: .1) The facility will ensure blood Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use . 3) The Glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus. On 11/9/23 at 7:20 AM,…

    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 · Dcited before2023-11-13 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 2 (R40, R20) of 12 residents were provided with personal privacy during medical treatment with the administration of medications (insulin and tear drops) and obtaining testing R40's blood sugar. * On 11/9/23, R40 was not provided with personal privacy during the administration of insulin and when R40's blood sugar was tested while in the dining room. * On 11/9/23, R20 was not provided with personal privacy when her tear drop medication was administered while in the dining room. Findings include: 1. R40 was admitted to the facility on [DATE] with diagnoses of Type Two Diabetes Mellitus, Hypertension and Dementia. R40's Annual MDS (Minimum Data Set) assessment dated [DATE] indicates a BIMS (Brief Interview for Mental Status) score of 04, indicating severe cognitive impairment. R40 was noted by surveyor to be non-interviewable at the time of this survey due to cognitive status. On 11/9/23 at 7:20 AM, Surveyor began to conduct 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
  • Potential for harm · D2023-11-13 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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, interviews and record review the facility did not ensure that residents are free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms and document ongoing re-evaluation of the need for restraints for 1 of 1 (R35) residents reviewed for restraints. R35 had a seat belt restraint in use on his wheelchair (w/c). There was no physician's order, careplan, consent or monitoring of the restraint. Findings include: The facility policy titled Restraint Free Environment which is not dated, documents (in part) . .It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Definitions: Physical Restraint refers to any manual method or physical or mechanical…

    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 · D2023-11-13 · 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 that residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 2 (R35) residents reviewed. R35 did not have a rolled up washcloth in his right hand per his care plan and therapy recommendations. Findings include: R35 admitted to the facility on [DATE] and has diagnoses that include Cerebral Palsy, quadriplegia, convulsions, Neuromuscular Scoliosis, Angelman Syndrome, Adult Failure to Thrive and muscle spasm. Surveyor noted R35 has contractures of bilateral upper and lower extremetities documented since admission. R35's Quarterly Admission/Readmission/Routine Head-to-toe Evaluation dated 10/19/23 documents: Musculoskeletal: Does the resident have contractures? Yes. Bilateral lower and upper extremities. Resident has severe contractures of upper and lower extremities due to Cerebral Palsy. R35's Quarterly Minimum Data Set…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the medication error rate was below 5%. During medication pass, surveyors observed 6 errors out of 32 opportunities with a medication error rate of 18.75%. 3 (R40, R20, and R50) of 6 residents observed during the medication administration task did not receive their medication as ordered. *R40 received their scheduled morning insulin (Humulin and Novolog) after eating 50% of their breakfast. *R20 received their scheduled Omeprazole - extended release reflux medication after eating 25% of their breakfast meal. According to the Assistant Director of Nursing (ADON)-C Omeprazole should be administered on an empty stomach. Surveyor informed ADON-C of observations of RN-G administering Omeprazole after R20 had began eating their breakfast meal. *R50 received their scheduled extended release reflux medication Omeprazole after eating 50% of their breakfast meal. R50 also received extended release seizure (Keppra) and pain medication (Tylenol).…

    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 · D2023-11-13 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure residents were free from significant medication errors for 3 (R51, R40 and R20) of 12 residents reviewed for medications. *R51 was admitted to the facility on [DATE] with an order for Augmentin (antibiotic) twice a day until 8/10/23. The facility incorrectly transcribed the order as Augmentin twice a day every 11 days. The incorrect transcription resulted in R51 receiving the Augmentin/antibiotic for two days (or 4 doses) instead of 11 days (or a total of 27 doses). R51's gangrene progressed resulting in a right lower extremity amputation (above the knee amputation). Vascular Surgery Registered Nurse (RN)- L informed Surveyor on 8/10/23 everything was looking good and that RN-L could not located documentation that vascular surgery was aware R51 did not receive the correct amount of Augmentin and had the NP who saw R51 on 8/10/23 been made aware of the missed doses of the Augmentin they may have ordered something different. Registered…

    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
  • No harm found · C2023-11-13 · tag F0623 — widespread
    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 record review and interview, the facility did not notify the resident and the resident's representative of a transfer or discharge in writing that includes the reasons for the transfer and the statement of the resident's appeal rights including the name, mailing address, email address, and telephone number of the entity which receives such requests, and the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman for 5 (R45, R51, R10, R30, and R35) of 5 residents reviewed for discharges. * R45 was transferred to the hospital on 7/20/23. R45 and R45's representative were not provided with a transfer notice. * R51 was transferred to the hospital on 8/21/23. R51 and R51's representative were not provided with a transfer notice. * R10 was transferred to the hospital on 8/24/23. R10 and R10's representative were not provided with a transfer notice. * R30 was transferred to the hospital on 8/13/23, 9/10/23, and 10/17/23. R30 and R30's representative were not…

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

    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.

Part of a chain

This home belongs to CHAMPION CARE — 22 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 52.3-0.3 vs chain
Quality measures 3 of 53.0≈ chain avg
The other 21 homes this chain runs (chain average 2.2★, per CMS)
1 of 5Burlington Health and Rehabilitation CenterBurlington, WI 1 of 5Lyonsview Health And Rehabilitation CenterKnoxville, TN 1 of 5Madison Health and Rehabilitation CenterMadison, WI 1 of 5Manahawkin Health And Rehabilitation CenterManahawkin, NJ 1 of 5Suring Health and Rehab CenterSuring, WI 1 of 5Waters Edge Health and Rehabilitation CenterKenosha, WI 2 of 5Avondale Health and Rehabilitation Center, LLCHumboldt, TN 2 of 5Beloit Health And Rehabilitation CenterBeloit, WI 2 of 5Eastview Health and Rehabilitation CenterAntigo, WI 2 of 5Highlands Health And Rehabilitation CenterMemphis, TN 2 of 5Muskego Health and Rehabilitation CenterMuskego, WI 2 of 5North Ridge Health and Rehabilitation CenterManitowoc, WI 2 of 5Oconto Health and Rehab CenterOconto, WI 2 of 5Riverside Health And Rehabilitation Center LLCTrenton, NJ 2 of 5Sheridan Health and Rehabilitation CenterKenosha, WI 3 of 5Monroe Health And Rehabilitation CenterMadisonville, TN 3 of 5Patriot Health and Rehabilitation CenterParis, TN 4 of 5Dyersburg Health And Rehabilitation CenterDyersburg, TN 4 of 5Nu Roc Health and Rehabilitation CTRLaona, WI 4 of 5Okeena Health And Rehabilitation Center LLCDyersburg, TNNot rated (Special Focus)Medical Suites at Oak Creek (The)Oak Creek, WI

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
THE BAY AT ST ANN HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/21/2020
RUVEL, MENACHEMIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 09/21/2020
WEINBERG, YISROELIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 09/21/2020
CHAMPION CARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2020

CMS files one row per role, so the 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$5.7M
Net patient revenuemost recent cost report
+3.3%
Operating marginrevenue minus expenses
$684K
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 37%Medicare 6%Other / private 57%

This home reported $684K paid to related parties — landlords or management companies under common ownership — equal to about 12% 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

$330per resident / day
operating cost
$10,041per month
≈ monthly operating cost
$342per 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 525731. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, 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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