Edenbrook Omro
500 Grant Ave, Omro, WI 54963 · For profit - Limited Liability company · 50 certified beds · (920) 685-2755 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (17) — 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)
- nursing-staff turnover (72%) runs well above the national median (45%)
- about 18% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.3% | 16.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.3% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.0% | 2.7% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 2.6% | 5.7% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.0% | 3.3% | 3.3% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 25.3% | 16.9% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.3% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 5.0% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 29.9% | 24.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.5% | 15.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 80.3% | 82.2% | 79.4% | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.7% 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 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.57 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.7%CMS range 31.6–61.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 7.3–17.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not 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 discharge | not 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 discharge | not 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 identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not 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 worsened | not 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 hospitalization | not 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 SNFs | 0.94 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 50 beds and averages 33.4 residents a day — about 67% occupied, or roughly 17 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 4.19 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.21 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.37 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.73 hrs/resident/day on weekends vs 4.38 on weekdays — 15% thinner on weekends. RN hours go from 1.37 to 0.81 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 72% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Actual harm · G2023-06-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure necessary care and services were provided to prevent pressure injuries from developing or worsening and/or promote healing for 2 Residents (R) (R10 and R30) of 4 sampled residents. R10 was admitted to the facility following a fall that resulted in a right hip fracture. R10 was assessed to be at risk for the development of pressure injuries. Interventions to elevate and protect R10's heels were not initiated until R10 developed suspected deep tissue injuries (DTIs) (areas of soft tissue damage due to pressure or shear which are anticipated to evolve into a deep PI, but have not yet done so. The affected skin is discolored purple or maroon, may be painful, firm, mushy, boggy, and warmer or cooler than adjacent skin. The wound may further evolve and become covered by eschar characterized by dark, crusty tissue at either the bottom or the top of a wound) to both heels approximately 3 weeks after admission. This example…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 resident (R) (R1) of 4 sampled residents. R1 was on enhanced barrier precautions (EBP) due to a suprapubic catheter. On 4/1/26, staff did not wear gowns while providing personal care for R1. Findings include: The facility's Enhanced Barrier Precautions policy, dated 3/2024, indicates: It is the policy of this facility that EBP, in addition to standard and contact precautions, will be implemented during high-contact resident care activities when caring for residents who have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as residents with chronic wounds requiring a dressing, indwelling medical devices .High-contact resident care activities include: Dressing, bathing/showering . On 4/1/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility 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.
- Potential for harm · D2025-10-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure a fall intervention was in place and post-falls assessments were accurately completed for 3 residents (R) (R1, R2, and R3) of 3 sampled residents.R1 had multiple falls since admission. R1's care plan contained an intervention for 2 body pillows when in bed. The intervention was not consistently implemented. In addition, R1's post fall assessments were not completed per policy.R2 had a fall on 10/1/25. R2's post fall assessments were not completed per policy.R3 had a fall on 10/5/25. R3's post fall assessments were not completed per policy. Findings include: The facility's Fall Reduction Policy, revised 10/13/23, indicates: Risk Identification and Assessment: .4. Identified risk factors should be discussed in the Care Area Assessment (CAA) documentation via the Minimum Data Set (MDS) and addressed in the resident's care plan to assure individualized interventions to reduce the risk are implemented. The facility's Post Fall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-09-10 · tag F0725 — failed to have enough nursing staff — widespreadProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, the facility did not ensure staffing was sufficient to meet care needs of residents. This had the potential to affect all 37 residents. Schedules were compared with daily census as well as the Facility Assessment and there were days staffing did not meet the needs of the daily census.Interviewed residents and family members indicated they waited a long time for call lights and call lights were observed to be turned off prior to the resident need being met. Interviews revealed weekends were more challenging because there was no office staff to assist as needed.Interviewed staff which revealed that the facility has many 2 person assist transfers and high acuity residents which affects care needs being met as well as meal times. Based on observation, staff and resident interview, and record review, the facility did not ensure there was sufficient staff to meet resident's needs. This practice had the potential to affect all 37 residents residing in the facility. 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.
- Potential for harm · D2025-09-10 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) document was accurate for 1 resident (R) (R1) of 14 sampled residents.R1's POAHC document was not in accordance with R1's wishes. The facility did not review the document with R1 to ensure accuracy.Findings include:From 9/8/25 to 9/10/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including paranoid schizophrenia, generalized anxiety disorder, congestive heart failure, and chronic pain. R1's Minimum Data Set (MDS) assessment, dated 8/29/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker.On 9/8/25, Surveyor reviewed a POAHC document signed by R1 on 6/8/12 that contained the names of POAHC-D, POAHC-E, and POAHC-F. Surveyor reviewed the contact list in R1's medical record and noted POAHC-D, POAHC-E, and POAHC-F were not on R1's contact list.On 9/9/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure assistance for activities of daily living (ADLs) was provided in a timely and consistent manner for 2 residents (R) (R3 and R1) of 3 sampled residents.R3's plan of care indicated R3 should receive a weekly shower on the Thursday PM shift. R1's plan of care was not consistently followed. R1's plan of care indicated R1 should receive 2 full bed baths weekly. R1's plan of care was not consistently followed. Findings include:The facility's Activities of Daily Living (ADLs) policy, revised 2/25/25, indicates: .2. The facility will provide care and services for the following activities of daily living. Bathing and Hygiene: Assistance with bathing or showering and maintaining personal hygiene .9. If a resident refuses care, this shall be reported to the nurse and the resident reapproached. Documentation of refusal shall be completed in the electronic medical record.1.From 9/8/25 to 9/10/25, Surveyor reviewed R3's medical record. R3 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.
- Potential for harm · E2024-10-16 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy when 1 of 2 medication carts was observed unlocked and unattended during medication pass. This practice had the potential to affect more than 4 of the 31 residents residing in the facility. On 10/16/24, the 100 wing medication cart was left unlocked and unattended during medication administration for 3 residents (R) (R6, R7, and R4). Findings include: The facility's Administering Medications policy, dated 1/2024, indicates: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations .Procedure: .18. Medications will remain secured in a locked cabinet/cart unless in direct view of the individual administering the medication. The facility's Medication Storage policy, dated 2/2024, indicates: To ensure medications and biological are stored in a safe, secure storage and safe handling .General Guidelines: .7. Compartments containing medications should be locked…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-16 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection for 6 residents (R) (R6, R8, R9, R10, R11, and R4) of 12 sampled residents observed during medication administration. On 10/16/24, Licensed Practical Nurse (LPN)-D did not complete hand hygiene during medication administration for R6, R8, R9, and R10. On 10/16/24, Registered Nurse (RN)-E did not sanitize the blood pressure cuff between use for R11 and R4. Findings include: The facility's Hand Hygiene policy, dated 1/16/23, indicates: To provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections .Using Alcohol-Based Hand Gel: .c. Before preparing or handling medications; d. Before applying gloves and after removing gloves or other PPE. The Centers for Disease Control and Prevention (CDC) website's Guideline for Disinfection and Sterilization in Healthcare Facilities, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-16 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure 3 residents (R) (R6, R7, and R4) of 12 sampled residents were assessed as able to safely and accurately self-administer medication. On 10/16/24, Surveyor observed Licensed Practical Nurse (LPN)-D leave a cup with medication on R6's bedside table. R6 did not have a physician's order or an assessment that indicated R6 could self-administer medication. On 10/6/24, Surveyor observed Registered Nurse (RN)-E leave a cup with medication on R7's table for R7 to self-administer. R7 did not have a physician's order or an assessment that indicated R7 could self-administer medication. On 10/16/24, Surveyor observed RN-E leave cups with medication R4's table for R4 to self-administer. R4 did not have a physician's order or an assessment that indicated R4 could self-administer medication. Findings include: The facility's Administering Medications policy, dated 1/2024, indicates: To ensure safe and effective administration of medication 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.
- Potential for harm · D2024-10-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R3) of 4 sampled residents had a call light within reach. On 10/16/24, R3 was observed in R3's room without a call light within reach. Findings include: On 10/16/24, Surveyor requested the facility's call light policy which was not provided. On 10/16/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including spastic quadriplegic cerebral palsy, generalized anxiety disorder, unspecified behavioral and emotional disorders, unspecified intellectual disabilities, muscle wasting and atrophy, and cognitive communication deficit. R3's Minimum Data Set (MDS) assessment, dated 7/3/24, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R3 had intact cognition. R3's pain care plan, dated 6/30/24, contained interventions to assist R3 to meet needs, maintain safety, and keep R3's call light within reach. On 10/16/24 at 10:45 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.
- Potential for harm · D2024-10-16 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not provide pharmaceutical services to ensure an allergy was conveyed prior to a medication order for 1 resident (R) (R1) of 12 sampled residents. R1 had an allergy to Zofran which was documented in R1's hospital discharge summary and the facility's admission orders. R1 was administered Zofran on 9/6/24 and 9/7/24. Findings include: The facility's Administering Medications policy, dated 1/2024, indicates: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations .Procedure: 4. Medications shall be administered per provider's written/verbal orders upon verification of the right medication, dose, route, time, and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. On 10/16/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · Dcited before2024-07-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R9 and R434) of 4 sampled residents received the necessary care and services to prevent and/or monitor weight loss. R9 had an order to be weighed 3 times per week. R9's weights were not completed in accordance with the physician's order. In addition, R9 experienced a significant weight loss of 14.29% from 3/22/24 to 7/2/24. R434 was admitted to the facility on [DATE] and had an order for weights to be completed for the first 7 days after admission and one time a day every Monday, Wednesday, and Friday. R434's weights were not completed in accordance with the physician's order. Findings Include: The facility's Resident Height and Weight policy, with a revision date 7/7/23, indicates: A significant weight change is defined as a 5% weight change over 30 days, 7.5% weight change over 90 days, or a 10% weight change over 180 days .Upon admission and two days following, the nursing department staff will weigh the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-24 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure staff performed proper hand hygiene for 1 resident (R) (R2) of 3 residents observed during the provision of care. Registered Nurse (RN)-C did not perform appropriate hand hygiene during care for R2 on 7/22/24. Findings include: The facility's Hand Hygiene policy, with a revision date of 1/16/23, indicates: To provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aide in the prevention of the transmission of infections .2. The use of gloves does not replace hand hygiene. 3. Hand hygiene is always the final step after removing and disposing of personal protective equipment (PPE). In addition, the policy indicates staff should perform hand hygiene under the following conditions: Before applying gloves and after removing gloves; After handling items potentially contaminated with blood, body fluids, or secretions; Before moving from a contaminated body site to a clean body site during…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-06-14 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 36 residents residing in the facility. The facility did not have a system for preventing the growth and spread of Legionella in the facility's water system. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Include water management team members who were knowledgeable about Legionella - Identify acceptable ranges of control limits and corrective actions when control limits are not met Findings include: The 7/6/18 revised CMS (Centers for Medicare and Medicaid Services) Quality, Safety and Oversight Letter 17-30 titled, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) states: Facilities…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-14 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a physician was notified of a change in weight for 1 Resident (R) (R30) of 2 residents reviewed for nutrition. R30's weight decreased 7.5 pounds from 5/31/23 through 6/9/23. R30 lost 5.34% of R30's body weight in a nine-day period. R30's physician was not notified of the weight loss. Findings include: The facility's undated Resident Heights and Weights policy contained the following information: A significant weight change is defined as a 5% weight change over 30 days, 7.5% weight change over 90 days or a 10% weight change over 180 days .If a re-weigh verifies a significant, unplanned weight change, this is communicated to the resident's Physician, POA (Power of Attorney), Dietitian and any others deemed necessary by the Interdisciplinary team. The facility's Change in Condition policy, revised 7/6/21, contained the following information: .2. Specific information that requires a prompt notification includes, but is not limited to: e.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not provide care and services to maintain acceptable parameters of nutritional status for 1 Resident (R) (R30) of 2 residents reviewed for nutrition. R30's weight decreased 7.5 pounds from 5/31/23 through 6/9/23. R30 lost 5.34 % of R30's body weight in a nine-day period. R30's nutrition plan was not revised to add supplements after R30 lost weight and developed a pressure injury. Findings include: The facility's undated Resident Heights and Weights policy contained the following information: A significant weight change is defined as a 5% weight change over 30 days, 7.5% weight change over 90 days or a 10% weight change over 180 days .If a re-weigh verifies a significant, unplanned weight change, this is communicated to the resident's Physician, POA, Dietitian and any others deemed necessary by the Interdisciplinary team. The policy also indicates if a resident's weights identify a significant weight change, the resident's care plan is updated with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-14 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure pharmacy recommendations were addressed by a physician for 2 Residents (R) (R3 and R6) of 5 residents reviewed. Two out of three pharmacy recommendations for R3 did not contain a response from R3's physician. Two out of six pharmacy recommendations for R6 did not contain a response from R6's physician. Findings include: The facility's Medication Regimen Review policy, dated of 3/6/19, contained the following information: .6. Any irregularities will be communicated to the physician utilizing a written recommendation and report for consideration. 1. R3 was admitted to the facility on [DATE] with diagnoses that included post traumatic stress disorder (PTSD), generalized anxiety disorder, paranoid schizophrenia, and major depressive disorder. On 10/26/22, the pharmacy reviewed R3's medications and recommended a dose reduction for the following psychotropic medications: ~temazepam (a benzodiazepine) 15 mg (milligrams) by mouth at bedtime for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to EDEN SENIOR CARE — 21 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.6 | +1.4 vs chain |
| Health inspection | 4 of 5 | 2.5 | +1.5 vs chain |
| Staffing | 2 of 5 | 3.1 | -1.1 vs chain |
| Quality measures | 3 of 5 | 3.3 | -0.3 vs chain |
The other 20 homes this chain runs (chain average 2.6★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FEINSTEIN, DAN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 12% | since 12/04/2018 |
| LIFSICS, CHANNIE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 9% | since 12/04/2018 |
| POLSTEIN, MORDECHAI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 16% | since 12/04/2018 |
| STESEL, MAXIM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 45% | since 12/04/2018 |
| RICE, PAMELA | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/04/2018 |
| WATSON, WILLIAM | Individual | W-2 MANAGING EMPLOYEE | — | since 12/04/2018 |
| MAUER, DOVIE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/04/2018 |
CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 76% 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 $741K paid to related parties — landlords or management companies under common ownership — equal to about 18% 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525406. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.