Complete Care at Grande Prairie

Location & what’s nearby

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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

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.

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.

50.7% 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 162 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 69.1% 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 55 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 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% 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.

Staffing

How full it usually is: this home is certified for 118 beds and averages 88.8 residents a day — about 75% occupied, or roughly 29 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 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 3.04 hrs/resident/day on weekends vs 3.60 on weekdays — 16% thinner on weekends. RN hours go from 0.84 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% 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.

21 citations, most serious first. The 13 most serious are shown; the remaining 8 are one tap away and print in full.

• Immediate jeopardy · Kcited before2025-03-27 · tag F0610 — failed to investigate and act on abuse reports — pattern
  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 thoroughly investigate 2 of 4 allegations of abuse involving residents (R) (R5 and R1) and did not take steps to prevent further potential abuse while an investigation was in progress. The facility was made aware of an incident involving allegations of abuse that occurred involving R5 and two staff members. The facility did not investigate the incident causing R5 to be fearful and cautious. R5 sought evaluation and treatment for left knee pain following the incident. The staff member alleged to have abused R5 was allowed to work approximately 46 shifts following the incident, resulting in R5 and other residents to not be safeguarded from additional potential abuse. The facility's failure to thoroughly investigate allegations of abuse allowed accused staff to continue working with residents following the incident resulting in the failure to safeguard residents from potential further abuse. These failures created a finding of Immediate Jeopardy that began…

  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
• Actual harm · G2025-03-27 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to protect the residents' right to be free from verbal and or physical abuse by Certified Nursing Assistant (CNA)-J. *R5 reported that R5 was attacked in the doorway of the kitchen, in the dining room, at the facility resulting in R5 to be fearful and cautious in the facility. R5 reported left shoulder, left rib and left knee pain following the incident. R5 sought evaluation and treatment for R5's left knee pain on 01/13/2025 resulting in R5 requiring an invasive injection into R5's left knee. Findings: Findings include: The facility's policy, titled Abuse, Neglect and Exploitation, dated as reviewed/revised on 10/2024, documents: Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-27 · 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 observation, interview, and record review, the facility did not ensure residents received adequate supervision and assistive devices to prevent accidents for 1 (R6) of 2 residents reviewed for falls. R6 was assessed as needing bilateral enabler bars on the bed to assist with positioning and bed mobility. An enabler bar was placed on the left side of the bed. No enabler bar was placed on the right side of the bed. R6's care plan had the intervention of bilateral enabler bars until 1/7/2025 when the care plan was revised to reflect what was actually in place, the left enabler bar only. On 3/10/2025, Certified Nursing Assistant (CNA)-C was providing cares to R6 and rolled R6 away from CNA-C. R6 continued to roll to the right and fell out of bed sustaining a right hip fracture requiring surgical intervention. The post-fall intervention was to place an enabler bar to the right side of the bed, which should have been in place per the admission assessment for siderail use. Findings include: The facility'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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-05-14 · 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, record review, and interview, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety (Wisconsin Food Code) in the main kitchen. This deficient practice has the potential to affect all 79 residents who receive food from the main kitchen. *Dietary Manager (DM)-C, Dietary Aide (DA)-D, and DA-E were observed in the main kitchen preparing and handling food without wearing hair restraints that covered facial hair. DA-E was observed wearing a hat that did not fully restrain hair. Findings include:The Wisconsin Food Code documents: Food employees shall wear hair restraints such as hair coverings or nets, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food.On 5/11/26 at 8:27 AM, Surveyor conducted an initial tour of the main kitchen with DM-C. Surveyor observed DM-C handling food in the main kitchen while not wearing a hair restraint for exposed facial hair. On 5/12/26 at 8:18 AM, Surveyor observed DM-C handling food in the main…

  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 · F2026-05-14 · tag F0851 — widespread
  Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not ensure it submitted accurate mandatory staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 79 residents residing in the facility.Staffing information for Quarter 1 (October 1 - December 31, 2025) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.Findings include:The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, documents: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-05-14 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, drugs used in the facility were not labeled in accordance with currently accepted professional principles. *Surveyor observed 6 expired stock medications and 63 loose medication pills in 2 of 3 medication carts.This deficient practice has the potential to affect more than 3 residents residing on the units that utilize the medication carts for medication administration. Findings:The facility's policy, titled Medication Storage, with an implement date of 3/2026, does not document any policies regarding expired medications.On 05/12/2026, at 12:47 PM, Surveyor observed medication pass on the MESA unit with Licensed Practical Nurse (LPN)-N. Within the medication cart, Surveyor observed Vitamin B with an expiration date of 4/2026, Thiamin with an expiration date of 4/2026, Cetirizine unable to read expiration date with no open date, Non-aspirin no expiration date and Senna S- no expiration date. LPN-N asked the Unit Manager about the dates and the Unit Manager stated…

  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 · D2026-05-14 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  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 are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding, including risk for dehydration for 1 (R8) of 2 residents reviewed for enteral feeding.*R8 has an order for 12 hours continuous feed from 8PM to 8AM. Surveyor observed that on 5/11/2026, 5/12/2026 and 5/13/2026 that R8's tube feeding was not administered as ordered.Findings include:The facility policy, titled Enteral Tube Feeding via Continuous Pump, updated 12/14/2025, documents: Documentation The person performing this procedure should record the following information in the resident's medical record: . 2. Amount and type of enteral feeding. 7. If the resident refused the procedure, the reason(s) why and the intervention taken. Reporting . 3. Notify the supervisor if the resident refuses the procedure.R8 was admitted to the facility on [DATE] with diagnoses including gastrostomy (a surgical opening made…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-14 · tag F0699 — isolated
  Provide care or services that was trauma informed and/or culturally competent.
  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 3 (R7, R12, & R91) of 3 residents reviewed for post-traumatic stress disorder (PTSD) received trauma informed care in accordance with professional stands of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization. R7, R12, and R91 were admitted to the facility with a diagnosis of PTSD, and the facility did not develop a person-centered care plan identifying triggers, interventions, or monitoring for PTSD. Findings include: The facility policy titled Trauma Informed Care with implemented date March 2026 documents: The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-27 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2.) Surveyor reviewed a facility investigation regarding a resident to resident physical altercation between R3 and R4. This incident was reported to the state agency. R3 was admitted to the facility on [DATE] with diagnoses of quadriplegia, type 2 diabetes, and anxiety. R3's annual MDS (minimum data set) dated 2/8/25 indicates R3 is cognitively intact and is dependent for ADLs (activities of daily living). R4 was admitted to the facility on [DATE] with diagnoses of ESRD (end stage renal disease), type 2 diabetes, and PTSD (post traumatic stress disorder). R4's quarterly MDS dated [DATE] documents that R4 is cognitively intact and independent for ADLs. The facility investigation dated 1/24/25 documents that R3 was in bed and thought R4 was trying to climb in bed with him. R3 then threw water at R4 and R4 retaliated by throwing a fan at R3 hitting R3 in the shin. The investigation reveal R4 denied trying to get in bed with R3. R4's statement indicated the room was dark and he was walking and touched R3's bed on…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-11-14 · tag F0554 — isolated
  Allow 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 observations, interviews, record review, and facility policy review, the facility failed to assess two of 18 sampled residents (Resident (R) 11 and R45) for self-administration of medications. This failure led to medications being left at the bedside where they could be accessed by other residents. Findings include: Review of a facility policy titled Resident Self-Administration of Medication dated 2024 indicated .It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered.Residents are offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team.When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should be at a minimum consider the following.The medications appropriate and safe 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-11-14 · tag F0812 — failed to store, cook, and serve food safely — isolated
  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, record review, and policy review, the facility failed to ensure leftovers were cooled properly, over easy eggs were pasteurized or cooked thoroughly for one (Resident (R)55) of one resident, and the ice machine was routinely cleaned in one of one kitchen reviewed for food handling practices. This deficient practice had the potential to cause food-borne illness and affect 32 of 33 residents who received meals prepared in the facility's only kitchen. Findings include: Review of the facility policy titled Ice Machine, revised 06/12/24, revealed Frequency: Monthly- Remove ice, Wash inside machine, Use sanitizing solution and clean cloth, Allow to air dry, Refill with ice. Review of the facility policy titled Cooling Monitor for Hazardous Foods, dated 05/01/19, revealed Food handling rules for cooling hazardous foods will be used by Dietary employees. Hazardous foods will be defined as: . eggs . Procedure: Transfer cooked product to a container(s) with a depth no greater than two inches, . Leave container uncovered or loosely covered during the cooling…

  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 · D2024-11-14 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and policy review, the facility failed to ensure two of two Licensed Practical Nurses (Licensed Practical Nurses (LPN) 3 and LPN 5) followed Enhanced Barrier Precautions (EBP) during medication administration for two of two residents (Resident (R) 68 and R231). Findings include: Review of the facility's revised October 2024 Enhanced Barrier Precautions policy revealed EBP would have been followed when providing high-contact resident care activities including feeding tubes and PICC (peripheral inserted central catheter) lines. During an observation on 11/13/24 at 8:50 AM of LPN3 during medication administration through a gastrostomy tube (tube inserted into the stomach) for R231 revealed she did not put on a barrier gown prior to accessing his gastrostomy tube. There was an EBP sign on R231's door and supplies beside the door. During an interview on 11/13/24 at 2:52 PM with LPN3 revealed she did not put a barrier gown on as she did not feel there was no risk of any type of infectious transmission. She agreed she should have used the barrier gown…

  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 · D2024-01-08 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the Facility did not ensure the medical record contained advanced directives for 1 (R5) of 5 residents. On 10/2/23 SW (Social Worker)-F received physician's statement of incapacity form from Physician-H for R5. As of 1/4/24 there has been no follow up from the Facility for a 2nd physician signature to activate R5's healthcare power of attorney. Findings include: The Residents' Rights Regarding Treatment and Advanced Directives policy last revised 10/23 under Policy Explanation and Compliance Guidelines includes 4. The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities. R5's diagnoses includes dementia, hypertension, anxiety, and chronic kidney disease. The quarterly MDS (Minimum Data Set) with an assessment reference date of 11/28/23 has a BIMS (Brief Interview Mental Status) score of 12 which indicates moderate cognitive impairment. The social service note dated 9/28/23 written by SW (Social…

  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.

Fines & penalties

$65,556 in federal fines across 1 penalty.

• $65,556 — penalty dated 2025-03-27

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to COMPLETE CARE — 85 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 →

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

CMS files one row per role, so the 26 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $780K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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