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Christian Community Home Of Osceola, INC

2650 65th Ave, Osceola, WI 54020 · Non profit - Other · 40 certified beds · (715) 294-1100 Medicare & Medicaid certified

Call the home — (715) 294-1100 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0607, F0609, F0610) — most recent May 2026Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure 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.

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

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
216 S Adams St · (715) 483-3221 · Call to confirm hours
Pharmacy
2600 65th Ave · (715) 294-4050 · Call to confirm hours
Grocery
112 Chieftain St · (715) 294-2158 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 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 rating2★
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 increased30.3%16.1%15.4%worse
Long-stay residents who lose too much weight0.0%5.1%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder10.9%2.1%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection5.6%2.7%2.0%worse
Long-stay residents with depressive symptoms0.0%5.7%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury17.3%3.3%3.3%worse
Long-stay residents whose ability to walk worsened29.3%18.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication8.0%16.9%18.9%better
Long-stay residents given the seasonal flu vaccine90.0%95.0%95.3%typical
Long-stay residents with pressure ulcers11.1%5.0%4.7%worse
Long-stay residents with worsening bladder/bowel control39.0%24.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table18.8%15.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine87.5%82.2%79.4%better
Short-stay residents rehospitalized after admission19.2%23.1%22.6%better
Short-stay residents with an outpatient ER visit23.7%15.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.621.661.67better
Long-stay outpatient ER visits per 1,000 resident days1.852.291.80typical

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

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

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

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

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

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

59.0% 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 79 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.0%U.S. median 51.5%
Got home and stayed home
9.3%U.S. median 10.7%
Went back to hospital
47.2%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 47.2% 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 53 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 0.31 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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 SNF59.0%CMS range 49.9–68.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.3%CMS range 6.2–14.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge47.2%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 discharge37.7%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 discharge37.7%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 identified93.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.7%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 hospitalization5.7%CMS range 3.2–10.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 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

0.79
RN hours/ resident / day
0.60
LPN hours/ resident / day
3.03
Aide hours/ resident / day
4.42
Total nurse hours/ resident / day
0.59
RN hoursweekends
51.7%
Total nursing turnover
45.5%
RN turnover

How full it usually is: this home is certified for 40 beds and averages 37.0 residents a day — about 92% occupied, or roughly 3 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 4.42 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.03 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.09 hrs/resident/day on weekends vs 4.55 on weekdays — 10% thinner on weekends. RN hours go from 0.87 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

10
deficiencies at the latest standard inspection (2025-05-07)
10
at the previous standard inspection (2024-04-04)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · D2026-05-27 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not report an allegation of neglect to the State Survey Agency or local law enforcement within 24 hours after being made aware of the allegation for 1 of 1 resident (R1) reviewed.On 05/10/26 at 10:56 PM, Director of Nursing (DON) B was notified via email by Certified Nursing Assistant (CNA) D of a neglect concern regarding R1. DON B did not submit a Misconduct Incident Report to the State Survey Agency after being made aware of concern.This is evidenced by:On 05/26/26 at 8:39 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding quality of care of residents and reporting grievances. CNA D stated on 05/10/26, CNA D sent an email to DON B (Director of Nursing) regarding concerns of neglect. CNA D stated upon starting her PM shift, CNA D entered R1's room and found R1's incontinent brief to be overly saturated with urine and R1's legs and chest were wet with urine. CNA D stated she checked the CNA report sheet, and no one had documented changing R1's incontinent briefs since 8:15 AM. Surveyor asked CNA D if the DON…

    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 · D2026-05-27 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not complete a thorough investigation after being made aware of a concern of neglect for 1 of 1 resident (R1) reviewed.On 05/10/26 at 10:56 PM, Director of Nursing (DON) B was notified via email by Certified Nursing Assistant (CNA) D of a neglect concern regarding R1. The facility did not immediately begin a thorough investigation of reported neglect, collect information that corroborates or disproves the incident, and document the findings.This is evidenced by: On 05/26/26 at 8:39 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding quality of care of residents and reporting grievances. CNA D stated on 05/10/26, CNA D sent an email to DON B regarding concerns of neglect. CNA D stated upon starting her PM shift, CNA D entered R1's room and found R1's incontinent brief to be overly saturated with urine and R1's legs and chest were wet with urine. CNA D stated she checked the CNA report sheet, and no one had documented changing R1's…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 interview, observation and record review, facility did not implement professional standards of practice to ensure a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent new PIs from developing for 1 of 3 residents (R1) reviewed.R1 was assessed as high risk for PI development. The facility failed to implement interventions to prevent PI development, ensure treatment orders were completed as ordered, and failed to complete a comprehensive assessment upon discovery of a new avoidable PI on R1's buttocks. This is evidenced by:Facility policy titled, Skin Alteration Policy and Procedure, with no date, states: Purpose: To establish a comprehensive facility program to maintain optimal skin condition for the residents.Policy: Nursing assessment will be utilized to identify residents at risk for the development of pressure injuries and appropriate plans of care for these residents will be established. Through the use of a skin protocol, all…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that falls were thoroughly investigated to determine root cause, new safety interventions implemented, staff education, and monitoring of effectiveness of interventions for 1 of 3 residents (R4) reviewed.-On 12/03/25, R4 sustained a fall. Facility determined root cause of fall was that staff did not follow R4's care plan interventions of:Pressure alarms in place on bed and chair (10/02/25). Pressure and laser alarm (10/02/25). Tab alarm (10/02/25).-After fall on 12/03/25, new intervention of checking R4 every 2 hours at bedtime for alarm placement was implement. No documentation on staff education following fall and new intervention.-On 12/23/25, R4 had a fall. No new interventions were implemented. No documentation on staff education. Interventions implemented after -On 02/02/26, R4 had a fall. No new interventions were implemented. No documentation on staff education.-On 03/19/26, R4 had a fall. Care plan was not updated after fall. No…

    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 · Fcited before2025-05-07 · 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, interview, and record review, the facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness to 33 out of 33 residents reviewed. The kitchen cooler contained a variety of foods not labeled with open or use-by dates. Cook Q had personal beverages on the food prep table. Findings include: Surveyor reviewed the policy titled, Food Safety and Sanitation, which states in part, .#4: All time and temperature control for safety (TSC) foods (including leftovers) should be labeled, covered, and dated when stored. Surveyor reviewed the policy titled, Personal Hygiene and Health Reporting, which states in part, .#1: Street clothing, coats, purses, packages, and other personal effects will be stored in employee lockers or designated storage areas and not in the kitchen . Example 1 On 05/05/25 at 9:12 AM, Surveyor toured kitchen area with [NAME] Q. Surveyor observed in kitchen cooler #10; Pulled pork opened with date of 4/30, red Jello in a container opened with no label, crushed pineapple in a container labeled 4/20, red tomato sauce 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-05-07 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of communicable diseases. The facility was not tracking infection surveillance accurately. These failures have the potential to affect 31 of the 31 residents. LPN L was observed touching medications with bare hands for 2 of 2 residents (R133 and R1) during medication pass. Improper hand hygiene observed for 2 of 4 residents (R8 and R23). Findings: The facility policy titled Nosocomial Infection Surveillance/Antibiotic Stewardship Program, states in part: The infection Preventionist is responsible for monitoring; investigating and setting forth a control plan to prevent unnecessary infections. The IP is responsible for monitoring and trending the facility infection incidence rates and this information is reviewed quarterly assurance committee with the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-07 · 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 record review, observation and interview, the facility did not ensure the resident environment remains free of accident hazards possible and each resident receives adequate supervision and assistance devices to prevent accidents. Facility did not assess residents for safe use of the EZ sit to stand lift for 5 out of 5 residents (R) (R23. R9, R21, R12, R17). Facility does not have a procedure in place to assess appropriate EZ Way Smart Stand mechanical lift (sit to stand) slings for accurate size and fit for each resident requiring use of the EZ stand lift for transfers. Certified Nursing Assistants (CNA) are determining what size sling to use for each resident. Findings include: EZ Way Smart Stand Manufactures Guidelines, dated10/24/24, states: To determine the correct sling size for an EZ Way Smart stand, consider the patient's weight, height, and girth. A proper sling size will comfortably support the patient and prevent any portion of them from overlapping the edges of the sling. Harness Color Coding…

    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 · Ecited before2025-05-07 · 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

    Based on observation, interview and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 5 of 5 residents (R) reviewed (R8, R14, R232, R11, R4). -Medication storage room had 2 opened unlabeled bottles of Lorazepam for resident (R8 and R14) with unknown expiration date. -Medication storage room had 1 opened and expired bottle of Amoxicillin for R232 stored in refrigerator that expired on 04/24/25. -Medication cart had R11's Morphine Sulfate liquid bottle opened unlabeled with unknown expiration date. -Observation of prescribed Nystatin powder left unattended in R4's room during 1 observation. Findings include: Facility policy titled, Storage of Medications, dated 05/2018 states in part: .Procedures: J. Medication storage conditions are monitored monthly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified. K. Refrigerated medications are kept in closed and labeled containers, with internal and external medications…

    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 · D2025-05-07 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 observation, interview and record review, the facility did not notify the physician on call of R4's refusal of insulin for 1 of 1 resident (R) reviewed for insulin administration (R4). Findings include: R4 was admitted to the facility on [DATE] with diagnoses including in part, type 2 diabetes mellitus with diabetic neuropathy, metabolic encephalopathy, chronic kidney disease stage 4, and acute and subacute hepatic failure without coma. Review of 4's medical record identified the following physician orders: - Insulin Aspart Injection Solution, inject 6 unit subcutaneously before meals for diabetes mellitus type 2 related to diabetes mellitus type 2 with hyperglycemia. Do not give insulin if Blood Glucose (BG) is less than 100. Observations: On 05/05/25 at 11:13 AM, Surveyor observed Registered Nurse (RN) C go into R4's room to check BG for insulin administration. R4's BG was 169. RN C indicated R4 is on sliding scale but does not require any insulin since BG is adequate. RN C indicated that R4 has been…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-07 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when one employee's background information disclosure (BID) was not obtained before employee started working at facility. (RN O). Findings include: The facility policy, titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised November 2022 states in part, Employee screening and training: a. Before new employees are permitted to work with resident's board registrations and certifications regarding prospective employee's background will be checked. d. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks. On 05/06/25 at 8:14 AM, Surveyor reviewed 8 random staff Background Information Disclosures (BID). Registered Nurse (RN) O was hired on 02/04/25.…

    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
Show the remaining 18 citations
  • Potential for harm · D2025-05-07 · tag F0659 — isolated
    Provide care by qualified persons according to each resident's written plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure prescription medications were administered by qualified staff for 1 of 8 residents (R) observedduring medication administration (R4). -Surveyor observed prescribed Nystatin powder at R4's bedside table. During medication administration, Registered Nurse (RN) O stated Certified Nursing Assistant (CNA) I applied prescribed Nystatin powder to resident (R4)'s skin earlier in the AM. Findings include: R4 was admitted to the facility on [DATE] with diagnoses including in part, type 2 diabetes mellitus with diabetic neuropathy, metabolic encephalopathy, chronic kidney disease stage 4, and acute and subacute hepatic failure without coma. Review of R4's medical record identified the following physician orders: -On 03/31/25, Nystatin external powder 100000 unit/GM, Apply to Skin topically three times a day for skin infection due to candida yeast. Apply 1 application to folds/under breasts. On 05/05/25 at 11:13 AM, Surveyor followed RN O into…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility did not ensure a resident who required substantial assistance for repositioning and toileting received timely assistance for 1 of 12 residents (R) reviewed for Activities of Daily Living (ADLs) (R23). R23 requested to use the bathroom and waited 36 minutes before being assisted into restroom, resulting in clothing change, feeling embarrassed and like she is a burden. Findings include: R23 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke) affecting the left side, hemiplegia and hemiparesis (partial paralysis), absence of part of digestive tract, history of urinary tract infections and vascular dementia with psychotic disturbance. R23's Minimal Data Set (MDS) assessment, dated 1/7/2025, indicates that R23 is cognitively intact, has clear speech, and understands others. R23's physical abilities are limited, requiring substantial assistance for position changes, transfer from bed to chair and transfers to the toilet.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-07 · 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 record review and interview, the facility did not ensure that 1 of 1 resident (R) reviewed received appropriate respiratory care during administration of respiratory therapy (R6). Registered Nurse (RN) O did not perform pre-respiratory assessments for R6 when administering nebulizer treatments. Findings include: The facility policy titled Nebulizer Treatments, revised August 2023 states in part: #6. Complete a pre-treatment lung assessment and listen to breathe sounds . R6 was admitted to the facility on [DATE] with diagnoses including iron deficiency anemia secondary to blood loss, bipolar disorder, and major depressive disorder. Review of R6's medical record identified the following physician orders: -On 05/01/25, Give albuterol sulfate inhalation nebulization solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate). Inhale 3 ml orally three times a day for cough for 10 Days. On 05/05/25 at 11:16 AM, RN O administered albuterol sulfate nebulizer inhalation to R6. RN O applied gloves and gave nebulizer…

    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 · Fcited before2024-04-04 · 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, interview, and record review, the facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness to 33 out of 33 residents reviewed. Cook touched ready-to-eat foods with contaminated gloves when serving meals. The facility did not ensure the foods were served at safe temperatures in accordance with professional standards for food safety. Staff identified the temperature of the pork tenderloin on the hot steam table at 132.6 degrees Fahrenheit when serving the lunch meal. The facility did not ensure dishes had proper sanitization completed by observations of low-temperature wash cycles and incomplete chemical solution testing. The kitchen cooler contained a variety of foods in cups not labeled with open or use-by dates. Dietary Aide (DA) laid personal belongings on the food prep table. Findings include: Surveyor reviewed the policy titled, Employee Sanitary Practices, which stated in part, - .#6: Use utensils to handle food, avoiding bare-hand contact with food. Surveyor reviewed the policy titled, Hand Washing, which stated 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-04-04 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not establish a water management program with measures to monitor the control measures in place. The facility did not ensure the standard of practice for infection surveillance and treatment and McGeer's criteria were being utilized in the facility's infection control program. This has the potential to affect all 33 of 33 residents (R) residing in the facility. Findings include: The facility policy, entitled, Water Management Policy for Legionnaires' disease, which is not dated, states in part: Infection Control - . Risk Assessment - . B. Implement general strategies for detecting and preventing Legionnaires disease: . c. Keep adequate records of infection control measures, including communication…

    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 · D2024-04-04 · 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 Example 2 R17 was admitted to the facility on [DATE] with diagnoses that included in part cognitive communication deficit, vascular dementia, abdominal pain, colitis and gastroenteritis, diverticulosis, GERD (gastroesophageal reflux disease), zoster (shingles), long term (current) use of anticoagulant, and atrial fibrillation. R17's MDS assessment, dated 2/13/24, indicated that R17 had frequent pain that was moderate and use of anticoagulant. R17's pain assessments were done quarterly with noted nonpharmacological interventions, pain scale, location, and use of PRN (as needed) Tylenol that helped with R17's pain. R17's pain interviews were completed quarterly with detailed information on R17's pain. Current pain control works for R17. R17's provider orders: *Warm foot soak PRN for foot/joint discomfort as needed. *Aqua K pad/moist heat for joint discomfort on 20-minute intervals, as needed. *Complete pain interview (3.0) in assessment tab every day shift every 91 day(s). *Complete pain assessment in 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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, interview and record review, the facility did not provide care consistent with professional standards to prevent development of a pressure injury and does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable for one of one resident reviewed for pressure injuries. Resident (R)12 developed an unavoidable stage 2 pressure injury while at the facility. Observations of poor infection control occurred during wound care. This has the potential to effect 1 of 1 resident observed for pressure injuries. Findings include: The facility policy, entitled Dressing Change Clean Technique, revision date June 2023, states: Policy: Licensed Nursing Staff will provide for a clean technique when changing dressings . procedure: . 9. Remove soiled dressings. 10. Place soiled dressings in a plastic Bag. Use red biohazard bag if necessary. 11. Remove soiled gloves and place gloves with soiled dressings. 12. Perform hand hygiene. 13. Put on new gloves. R12…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · 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 interviews and record reviews, the facility did not ensure that the resident's environment remained as free of accident hazards as possible for 2 of 4 residents (R4, R5). This is evidenced by: Example 1 The facility policy, entitled Fall/Injury Reporting, states in part: 5. Provide immediate safety interventions and document interventions. Utilize fall template for documentation in progress note. 6. Complete Falls Report forms 7. Initiate Fall Investigation 10. A Resident Fall Tracking log will be completed at the Interdisciplinary Team (IDT) meeting to assess trends for each resident and continue with implementation for a plan of prevention. 11. The IDT will audit the medical record for appropriate documentation and conduct a post fall review. 12. The IDT will then evaluate the fall and recommend intervention. The change in plan will then be documented in the resident Care Plan and Certified Nursing Assistant (CNA) care plan. Fall tracking tools will be tabulated quarterly and results reviewed by the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-04 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not ensure pain management orders were followed for 1 of 2 residents (R) reviewed for pain (R183). R183 was prescribed a pain medication with dosage to be given based on the pain scale. The facility did not provide the appropriate amount of pain medication based on R183's pain scale, giving less medication than prescribed. Findings include: R183 was admitted to the facility on [DATE] with diagnoses that included in part left knee joint replacement surgery, migraine, Parkinson's disease, dementia, cognitive communication deficit, diabetes, poly-osteoarthritis, chronic pain, and low back pain. R183's care plan stated: Pain/Comfort: Alteration in/Potential for alteration in comfort. Interventions included: *Resident will experience relief of pain as evidenced by: verbal report of relief of pain. *Resident will be kept as comfortable as possible. *Alter environment for comfort: Provide comfortable room temperature or remove/add blanket, sweater as…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-04 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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

    Based on observation, interview and policy review, the facility did not ensure that a resident was provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 resident (R9) reviewed. The facility did not ensure R9 was administered insulin appropriately based on the observation of the Licensed Practical Nurse (LPN) not priming the insulin pen before administration. This is evidenced by: The facility policy, entitled Insulin pens, dated 08/23, states: .-#8. Turn the dial to 2, push the plunger, and waste 2 units. -#9. Turn the dial to an appropriate number of units . On 04/03/24 at 7:25 AM, Surveyor observed LPN E draw 7 units of insulin glargine from R9's insulin glargine pen. Surveyor did not observe LPN E prime the insulin glargine pen with 2 units first before drawing the 7 units of insulin glargine. On 04/03/24 at 8:24 AM, Surveyor observed LPN E administer the 7 units of insulin glargine to R9's abdomen. Surveyor did not observe LPN…

    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 before2024-04-04 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. The facility did not ensure PRN (as needed) orders for psychotropic drugs are limited to 14 days. The facility did not ensure adverse consequence such as unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. This occurred for 1 of 5 residents (R) reviewed for unnecessary medications. (R4). This is evidenced by: The facility's policy entitled Psychotropic Use developed 01/21/14 and last revised August 2023 states: Purpose: To provide a standard means of monitoring residents that receive psychotropic medications to ensure that psychotropic use is necessary and that the resident does not have adverse reactions to the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · tag F0761 — failed to label and store drugs safely — isolated
    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

    Based on observation, interview and policy review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, did not ensure only authorized personnel had access to medication carts and did not ensure expired medications were removed from stock supply. This occurred for 2 of the 3 medication carts/storage rooms observed. During the three-day survey, 3 of 4 observations were made of medication carts left unlocked when unattended and out of view of staff. One observation was made of a lorazepam liquid bottle opened and not labeled with an open or expiration date stored in the E-hall medication storage room. One observation was made of an opened bottle of liquid Humalog vial not labeled with resident identification, nor with an open or expiration date label. Findings include: The facility policy, entitled Medication Administration, dated 08/23, states: .-When opening a new medication that is not in a card, mark medication with an open date and use-by date per pharmacy recommendation. -Medication carts…

    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 · D2024-04-04 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    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 the interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, the following elements: An Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use. This has the potential to affect all 33 residents in the building who may utilize antibiotics. The facility did not ensure the standard of practice for infection surveillance and treatment, and McGeer's criteria were being utilized in the facility's antibiotic stewardship program. The facility did not follow Standards of Practice (SOP) for Antibiotic Stewardship for antibiotic use for residents on the line list logs from [DATE] through [DATE] line lists. This is evidenced by: The Facility Policy entitled Nosocomial Infection Surveillance/Antibiotic Stewardship Program, dated 10/22, states in part: The infection Preventionist is responsible for monitoring; investigating and setting forth a control plan to prevent unnecessary…

    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 · Fcited before2023-03-01 · 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 observations and interviews, the facility did not serve food in accordance with professional standards for food service safety. This has the potential to affect all 27 residents in the facility. Exhaust fans over food prep area dirty No hand hygiene between glove changes This is evidenced by: On 02/27/23 at about 9:20 AM, Surveyor performed an initial tour of the kitchen with Director of Dietary (DD) C. Observations of the cooktop hoods were dirty and fuzzy. Surveyor asked DD C if they had a cleaning schedule. DD C indicated they did but due to staff shortages it doesn't always get done. Surveyor asked DD C who was in charge of cleaning the hoods. DD C indicated the lead cook used to do them, but she left. DD C indicated going forward they were going to talk with the Nursing Home Administrator about maintenance taking over at least getting the screens down for kitchen staff to wash. On 02/28/23 at about 12:06 PM, Surveyor was observing kitchen staff serving lunch. Surveyor observed [NAME] E remove their gloves, put on new pair of gloves, no hand hygiene in-between switching…

    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 · Fcited before2023-03-01 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Housekeeping staff was observed entering a resident room on Transmission Based Precautions (TBP) without wearing proper Personal Protective Equipment (PPE.) Contracted housekeeping staff did not receive training on facility infection control policies and procedures prior to working in the facility. This had the potential to affect all 27 residents in the building. TBP room was not labeled with correct signs to inform staff and visitors what PPE to wear when entering the room. This had the potential to affect all 27 residents in the building. No hand hygiene was offered to residents (R) prior to eating. This was observed for 11 of 27 residents (R1, R8, R17, R16, R11, R6, R12, R7, R22, R130, and R27.) The facility did not ensure 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-01 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 have a rationale documented in the resident's medical record for extending PRN (as needed) psychotropic medications beyond 14 days. This occurred for 3 of 3 residents (R) reviewed for PRN psychotropic medications. (R17, R26, and R19) The facility did not ensure residents who use psychotropic medications receive a gradual dose reduction (GDR). This occurred for 1 of 4 residents reviewed for psychotropic medications. (R11) R17 and R26 had orders for PRN Lorazepam (anti-anxiety medication) which was in place for greater than 14 days without a clinical rationale and no end date. R19 had a physician's order for as needed Haldol with a stop date of indefinite. This allowed R19 to receive the as needed psychotropic medication for longer than 14 days without an indication of use by the ordering physician. Facility did not follow up with physician on pharmacist recommendation for gradual dose reduction (GDR) of psychotropic medications for 1 of 4…

    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 · D2023-03-01 · 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, interview and record review, the facility did not ensure each resident's right to be free from physical restraints for 1 of 5 residents (R6) reviewed for falls The facility initiated bed and wheelchair alarms for fall prevention against R6's wishes. R6 was admitted to the facility on [DATE], and has diagnoses that include osteoarthritis, major depressive disorder, and dementia. R6's Minimum Data Set (MDS) assessment, dated 02/07/23, indicated that R6 has a Brief Interview for Mental Status (BIMS) of 14 which indicates R6 is cognitively intact and is his own decision maker. On 02/27/23 at 2:17 PM, on initial tour, Surveyor was interviewing R6 and asking R6 how things were going for them at the facility. R6 indicated they don't like the alarms on their bed and wheelchair. Surveyor asked R6 if they had any falls. R6 indicated they did not. R6 indicated there was a time recently that they were self transferring from wheelchair to bed and the tray table slipped and they lowered themselves to the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-05-07 · tag F0628 — widespread
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the State Long-Term Care Ombudsman of hospital transfer and discharge for 2 residents (R11 and R31) of 2 residents reviewed in the sample of 12. The facility failed to have a system in place to ensure notifying the State Long-Term Care Ombudsman of hospital transfers and discharges. This had the potential to affect all 33 residents that reside in the facility. R11 was hospitalized from [DATE] through 04/05/25 and the Ombudsman was not notified of that transfer to the hospital. R31 was discharged from the facility on 03/06/25 and the Ombudsman was not notified of discharge. This is evidenced by: Example 1 R11 was admitted to the facility on [DATE] with diagnoses, in part, of aortic stenosis, constipation, type 2 diabetes mellitus and irritable bowel syndrome with constipation. Record review identified R11 as having moderate impaired cognition and had an activated Power of Attorney for Health Care (POAHC). Record review identified R11 was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
CHRISTIAN COMMUNITY HOMES AND SERVICES INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/23/2017
ANDERSON, ELLIOTIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2022
BEBAULT, MIKEIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2023
DUNHAM, RHONDAIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2023
FAHS, DANIELIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2024
GERRITTS, JOHNIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2022
GIBSON, CRAIGIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2022
HERMANSEN, MELVINIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2022
JOHNSON, ERICIndividualMANAGING CONTROL - GOVERNING BODYsince 09/01/2021
MORK, AARONIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2023
SCHWAB, DEBRAIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2021
SIMONSON, DARYLIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2018
STAEBELL, ROBERTIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2022
STARR, JACKIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2020
ZAJAC, CLAIREIndividualMANAGING CONTROL - GOVERNING BODYsince 09/01/2021
KACZROWSKI, JAMESIndividualCORPORATE DIRECTORsince 01/06/2022
KLINGFUS, PAMELAIndividualCORPORATE OFFICERsince 05/17/2021
MCGEEHAN, HEIDIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/15/2018
MILNER, RENEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 21 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$5.0M
Net patient revenuemost recent cost report
-22.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 52%Medicare 24%Other / private 24%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$616per resident / day
operating cost
$18,739per month
≈ monthly operating cost
$503per 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 525706. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-07, 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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