Heritage Health Services
1119 N Wisconsin St, Port Washington, WI 53074 · For profit - Limited Liability company · 50 certified beds · (262) 284-5892 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $17,170 in federal fines (most recent 2024-09-12)
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (58%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
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
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 10.7% | 16.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.3% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 4.0% | 2.1% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 2.7% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 5.7% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.0% | 3.3% | 3.3% | better |
| Long-stay residents on antianxiety or hypnotic medication | 26.6% | 16.9% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.4% | 5.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.5% | 24.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.1% | 15.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.9% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 70.0% | 82.2% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 19.7% | 23.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 13.3% | 15.5% | 12.0% | worse |
* 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.
Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 6.8–17.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.82 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 50 beds and averages 29.5 residents a day — about 59% occupied, or roughly 20 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.17 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 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 3.25 hrs/resident/day on weekends vs 3.92 on weekdays — 17% thinner on weekends. RN hours go from 1.31 to 0.83 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% 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 fewer than at the previous inspection — improving. 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.
33 citations, most serious first. The 11 most serious are shown; the remaining 22 are one tap away and print in full.
- Immediate jeopardy · L2024-09-12 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not have a licensed nurse on duty to meet the needs of residents for approximately 2.5 hours on the [DATE] PM shift. This had the potential to affect 23 of 23 residents (R) residing in the facility. On [DATE], an agency nurse who worked the AM shift left the facility without licensed nurse coverage for the PM shift. The facility was without a nurse for approximately 2.5 hours. Due to not having a licensed nurse on duty, 3 residents (R10, R16, and R7) did not receive blood glucose monitoring in accordance with physician orders. Fourteen residents (R8, R9, R10, R11, R12, R5, R1, R13, R14, R15, R16, R7, R3, and R17) did not receive medication in accordance with physician orders. One resident (R5) was transported by ambulance to the emergency room (ER) without a nurse assessment. Seven residents (R7, R11, R12, R14, R16, R18, and R19) were full-code status and without a cardiopulmonary resuscitation (CPR)-certified nursing staff in the facility. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, staff interview, and record review, the facility did not ensure food was stored and served in a sanitary manner. This practice had the potential to affect all 25 residents residing in the facility. The kitchen cooler and dry storage area contained multiple open and undated food items. Staff did not follow appropriate hand hygiene procedures in the kitchen and while serving food. Findings include: On 3/10/25 at 9:35 AM, Surveyor and Account Manager (AM)-G began an initial kitchen tour. AM-G indicated the facility follows the Food and Drug Administration (FDA) Food Code. Food Labeling/Storage: The 2022 FDA Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-12 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect all 25 residents residing in the facility. The facility did not maintain infection surveillance logs to assist with the recognition of trends and patterns of infection. In addition, the facility did not monitor residents for signs and symptoms of infection. Hand hygiene was not offered or completed for residents prior to dining. Licensed Practical Nurse (LPN)-E did not complete appropriate hand hygiene during wound care for R1. Findings include: The facility's Infection Prevention and Control Program policy, revised 7/23/24, indicates: This facility has established and maintains 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-12 · tag F0868 — patternHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility did not ensure the required members of the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly. This practice had the potential to affect more than 4 of the 25 residents residing in the facility. The facility did not ensure the required members of the QAPI committee met at least quarterly from March 2024 through February 2025. Findings include: The facility's Quality Assurance and Performance Improvement (QAPI) Committee policy, dated 7/11/22, indicates: The Executive Director and the Director of Nursing are responsible and accountable for the development, implementation, monitoring, and leadership of the center's QAPI program. A core team of individuals will be appointed to spearhead the QAPI program and will engage in monthly QAPI meetings which will include the creation/modification of performance improvement plans (PIPs). The center's QAPI Committee may include the following team members: the Executive Director, Director of Nursing, Medical Director, Infection Preventionist, Life…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-12 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure vaccinations were offered or administered for 5 residents (R) (R1, R5, R7, R19, and R21) of 5 sampled residents. The facility did not offer R1, R5, R7, R19, or R21 the PCV20® vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance®) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults 65 years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-12 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure protective placement was obtained for 1 resident (R) (R1) of 3 sampled residents with a Guardian when the resident's nursing home stay exceeded ninety days. R1 was admitted to the facility on [DATE] with the consent of a legal Guardian. The facility did not pursue protective placement when the resident's stay exceeded ninety days. Findings include: State Statute Chapter 55.03(4) indicates court-ordered protective placement should be obtained for any resident admitted to a nursing home who has a legal Guardian and whose nursing home stay exceeds ninety days. State Statute Chapter 55.18 indicates protective placement is reviewed annually. On 3/10/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including paraplegia, epilepsy, and congestive heart failure. R1's Minimum Data Set (MDS) assessment, dated 12/17/24, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-12 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff, resident, resident representative interview and record review, the facility did not ensure 2 residents (R) (R5 and R14) of 2 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R5 was transferred to the hospital on 2/21/25. Neither R5 or R5's Guardian received a written transfer notice. R14 was transferred to the hospital on [DATE], 1/8/25, and 2/14/25. R14 did not receive a written transfer notice for any of the transfers. Findings include: The facility's Transfer and Discharge policy, dated 10/26/22, indicates: .7. Emergency Transfers/Discharges initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident: .d) Complete and send with the resident (or provide as soon as practicable) a Transfer Form .f) The original copies of the Transfer Form .Copies are retained in the medical record . 1. From 3/10/25 to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-12 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff, resident, resident representative interview and record review, the facility did not ensure a bed hold notice was provided for 2 residents (R) (R5 and R14) of 2 sampled residents. R5 was transferred to the hospital on 2/21/25. Neither R5 or R5's Guardian received a bed hold notice. R14 was transferred to the hospital on [DATE], 1/8/25, and 2/14/25. R14 did not receive a bed hold notice for any of the transfers. Findings include: The facility's Transfer and Discharge policy, revised 7/15/22, indicates: .7. Emergency Transfers/Discharges initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident: .i) Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as soon as possible, but no later than 24 hours after the transfer. 1. From 3/10/25 to 3/12/25, Surveyor reviewed R5's medical record. R5's Minimum Data Set (MDS) assessment, dated 12/28/24, indicated R5 was rarely/never understood. A staff 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.
- Potential for harm · Dcited before2025-03-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not provide the necessary care and treatment to promote healing and/or prevent impaired skin integrity for 1 resident (R) (R1) of 15 sampled residents. R1 was diagnosed with a rare skin condition. R1's care plan indicated staff should not use incontinence briefs for R1. During an observation of care on 3/11/25, staff removed an incontinence brief from R1 and applied a clean brief. Findings include: On 3/10/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including paraplegia, epilepsy, obsessive compulsive disorder, and excoriation disorder (also known as chronic skin-picking or dermatillomania; a mental illness related to obsessive-compulsive disorder characterized by repeated picking at one's skin resulting in areas of swollen or broken skin). R1's Minimum Data Set (MDS) assessment, dated 12/17/24, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R1 and R2) of 5 residents observed during the provision of cares. R1 was on enhanced barrier precautions (EBP). On 12/4/24 and 12/5/24, staff did not wear personal protective equipment (PPE) during the provision of care for R1. In addition, staff did not complete appropriate hand hygiene during a dressing change on 12/5/24. On 12/4/24 and 12/5/24, R1 and R2's uncovered catheter drainage bags were in contact with the floor. Findings include: The facility's Enhanced Barrier Precautions (EBP) policy, revised 8/8/24, indicates: EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities .High-contact resident care activities include: dressing,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-12 · tag F0609 — failed to report abuse allegations — patternTimely 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 staff interview and record review, the facility did not ensure an allegation of neglect was reported to the State Agency (SA) when the facility was without a licensed nurse for approximately 2.5 hours on 4/14/24. This had the potential to affect 14 of 23 residents. On 4/14/24, the facility was without a licensed nurse on the PM shift from approximately 3:02 PM until 5:35 PM. Three residents (R10, R16, and R7) did not receive blood glucose monitoring in accordance with physician orders. Fourteen residents (R1, R3, R5, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17) did not receive medication in accordance with physician orders or the facility's policy. One resident (R5) was transported by ambulance to the emergency room (ER) without a nurse assessment to determine R5's medical needs. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a revision date of 7/15/22, indicates: Neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 22 citations
- Potential for harm · D2024-09-12 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop 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 staff interview and record review, the facility did not implement their written policies and procedures that prohibit and prevent abuse for 3 of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure a thorough and timely background check was completed for Licensed Practical Nurse (LPN)-K, LPN-I, and Certified Nursing Assistant (CNA)-L. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a revision date of 7/15/22 indicates: It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-12 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the accurate acquiring, receiving, dispensing, and/or administering of drugs and biologicals to meet the needs of 1 resident (R) (R2) of 1 sampled resident. R2 did not have a physician's order for alprazolam (a sedative medication used to treat anxiety) from 8/30/24 to 9/3/24. R2 received alprazolam 6 times during that time period. Findings include: The facility's Medication Administration under General Guidelines policy, dated 1/2024, indicates: .Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so .Medication Administration: .3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR). Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-02-06 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility did not ensure a Registered Nurse (RN) was scheduled for at least 8 consecutive hours a day 7 days per week. This had the potential to affect all 25 residents residing in the facility. The facility did not have a RN on duty for 8 consecutive hours on 8/29/23, 10/4/23, 10/6/23, and 10/7/23. Findings include: Surveyor reviewed the facility's Payroll Based Journal information which indicated the facility did not have licensed nursing coverage 24 hours per day for the following quarters: Quarter 2-2023 (January 1-March 31), Quarter 3-2023 (April 1-June 30), Quarter 4-2023 (July 1-September 30), and Quarter 1-2024 (October 1-December 31). On 2/5/24 Surveyor requested the following daily schedules from Business Office Manager (BOM)-H: 3/26/23 through 4/2/23, 4/4/23 through 4/8/23, 4/20/23, 5/4/23, 6/1/23, 6/10/23, 7/22/23, 7/23/23, 8/5/23, 8/19/23, 8/29/23, 9/2/23, 9/17/23, 10/6/23 through 10/8/23, 10/13/23 through 10/15/23, 10/20/23 through 10/22/23, and 10/27/23 through 10/29/23. On 2/6/24 at 8:00 AM, BOM-H provided Surveyor with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-02-06 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, had a national certification for food service management and safety from a national certifying body, or who had an associate's or higher level degree in food service management or hospitality. This had the potential to affect all 25 residents residing in the facility. Findings include: On 2/4/24 at 10:30 AM, Surveyor interviewed [NAME] President of Success (VPS)-C who indicated Account Manager (AM)-O oversaw the facility's kitchen. On 2/4/24 via an email to Surveyor, Director of Operations (DO)-Q confirmed Registered Dietician (RD)-P was the facility's RD. DO-Q indicated RD-P worked at the facility five hours per week on Thursday and was available all other days via phone. DO-Q's email stated AM-O had a FPM (Food Protection Manager) certificate, had over two years experience, and was enrolled to complete AM-O's FSM (Food Service Manger) exam. On 2/5/24, District Manager…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-02-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, the facility did not ensure food was stored and served in a safe and sanitary manner. This practice had the potential to affect 25 of 25 residents residing in the facility. The kitchen cooler and dry storage area contained multiple open, undated, unclearly dated, and expired food items. Staff did not follow appropriate hand hygiene procedures when food was prepared and served. Kitchen equipment and food services areas were not in a clean and sanitary condition. Staff used an unsanitary practice when processing dishes. Findings include: On 2/4/24 at 10:30 AM, Surveyor completed an initial tour of the kitchen with [NAME] President of Success (VPS)-C who was unfamiliar with the kitchen, but assisted Surveyor with the tour. In a subsequent visit to the kitchen, District Manager (DM)-L indicated the facility followed the Food and Drug Administration (FDA) Food Code. 1. Food Labeling/Storage The FDA Food Code 2022 documents at 3-501.17 Ready-to-Eat,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-02-06 · tag F0851 — widespreadElectronically 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 staff interview and record review, the facility did not ensure it completed mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 25 residents residing in the facility. Staffing information for fiscal quarter, date range: Quarter 1 (October 1-December 31), Quarter 2 (January 1-March 31), Quarter 3 (April 1-June 30), and Quarter 4 (July 1-September 30) of the Payroll Based Journal (PBJ) were not correctly submitted to CMS. Findings include: The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, indicates: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-06 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy for 3 Residents (R) (R3, R11 and R17) of 25 sampled residents with the potential to affect multiple other residents. On 2/4/25, Surveyor observed an unattended and unlocked medication cart on multiple occasions. On 2/5/24, Surveyor observed an open and undated eye drop medication for R11 in the unit 3 medication cart. On 2/5/24, Surveyor observed an open and undated inhaler for R17 in the unit 3 medication cart. On 2/5/25, Surveyor observed an open and undated medication bottle for R3 in the unit 3 medication storage room. Findings include: The facility's Storage of Medications policy, revised 1/2023, indicates: Medications and biologicals are stored properly, following manufacturers' or pharmacy recommendations, to maintain their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-06 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and resident and staff interview, the facility did not maintain dignity for 2 Residents (R) (R10 and R12) of 12 sampled residents. R10 and R12 required feeding assistance. During the lunch meal on 2/5/24, staff did not sit down while feeding R10 and R12. Findings include: On 2/5/24 at 11:59 AM, Surveyor observed the dining room and witnessed the following: -At 12:01 PM, Surveyor observed R10 receive a plate of pureed food. While feeding R10, a staff member stood to the left of R10 and did not sit down. -At 12:07 PM, Surveyor observed R12 at the opposite end of the table from R10. R12 and R10 were the only two residents at the table. The staff member who was feeding R10 also began feeding R12. The staff member alternated between feeding R10 and R12 and did not sit down while feeding either resident. On 2/6/24 at 8:19 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-R who stated CNAs were responsible for feeding residents and should be seated while doing so. On 2/6/24 at 8:34 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who stated nurses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-06 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure protective placement was obtained for 3 Residents (R) (R3, R16, and R1) of 3 sampled residents. R3's medical record indicated R3 had a legal guardian upon admission and had court-ordered guardianship paperwork. R3's medical record did not contain protective placement documentation. R16's medical record indicated R16 had a legal guardian upon admission and court-ordered guardianship paperwork. R16's medical record did not contain protective placement documentation. R1's medical record indicated R1 had a legal guardian, but did not contain court-ordered determination of guardianship or protective placement documentation. Findings include: State Statute Chapter 55.03(4) indicates: The law requires a court-ordered protective placement for any resident admitted to a nursing home who has a legal guardian and whose nursing home stay exceeds sixty days, only to be extended with court approval (State Statute Chapter 55.05(b)). Protective placement is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-06 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and Power of Attorney (POA) interview and record review, the facility did not notify the POA for 1 Resident (R) (R25) of 2 sampled residents when the resident returned from the hospital. R25 was transferred to the hospital following a seizure and returned to the facility on [DATE]. R25's POA was not notified when R25 returned to the facility. Findings include: The facility's Change in Condition of the Resident policy, dated 9/20/22 indicates: A facility should immediately inform the resident, consult with the resident's physician; and notify consistent with his or her authority, the resident representative when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-06 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure written notification of financial liability via an Advanced Beneficiary Notice (ABN) was provided for 1 Resident (R) (R228) of 3 sampled residents. The facility did not provide an ABN to R228 when R228's Medicare Part A benefits ended on 11/21/23. R228 discharged home from the facility on 11/29/23. Findings include: On 2/05/24, Surveyor reviewed the Beneficiary Protection Notification Review documents for three residents whose Medicare A stay or benefit period ended. On 2/5/24, Surveyor reviewed R228's medical record. R228's review indicated R228's last covered Medicare Part A service date was 11/21/23. R228 was scheduled to discharge home on [DATE]; however, R228 remained at the facility for another week and discharged home on [DATE]. The document indicated an ABN was not provided to R228. R228's medical record indicated R228 was changed to private pay and R228's family member paid $2,219 on 11/22/23. On 2/6/24 at 11:12 AM, Surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-06 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 staff interview and record review, the facility did not ensure monitoring for adverse consequences of high-risk medications for 1 Resident (R) (R5) of 5 residents reviewed for unnecessary medications. R5 was prescribed gabapentin and divalproex (high-risk medications in the anticonvulsant class used to treat seizures). R5's care plan did not contain monitoring for adverse consequences of gabapentin or divalproex. Findings include: 1. On 2/6/24, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, polyneuropathy (weakness, numbness and pain in the hands and feet) and high blood pressure. R5's medical record contained the following orders: ~gabapentin capsule 100 mg (milligrams), give 1 capsule by mouth three times daily related to polyneuropathy. ~divalproex sodium tablet delayed release 250 mg, give 1 tablet by mouth in the morning for mood stability. Surveyor noted R5's care plan did not indicate R5 was prescribed high-risk…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-06 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 26 opportunities which resulted in a 7.69% medication error rate that affected 2 Residents (R) (R14 and R12 ) of 7 residents observed during medication pass. R14 was administered 10 units of insulin lispro (use to treat diabetes) injection solution 100 units/ml (milliliter) via insulin pen. Staff did not prime the insulin pen prior to administration. Staff did not check R12's heart rate and blood pressure prior to administering a diltiazem (Tiadylt) (used to treat high blood pressure and chest pain) extended release (ER) 300 milligram (mg) capsule. Findings include: The facility's Medication Administration General Guidelines policy, dated 1/2023, indicates: Medication Administration: 1. Medications are administered in accordance with written orders of the Prescriber. 2. Obtain and record any vital signs as necessary prior to medication administration. 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.
- Potential for harm · Dcited before2024-02-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not provide the necessary care and services to maintain the highest practical physical well being related to nursing assessment and a change in condition for 1 Resident (R) (R25) of 14 sampled residents. On [DATE], R25 returned from the hospital following a seizure at the facility on [DATE]. Staff did not assess R25 for over 12 hours after R25 returned. Findings include: The facility's Change in Condition of the Resident policy, dated [DATE], indicates: .When a resident presents with a possible change in condition, after a fall or other possible trauma, or noted changes in mental or physical functioning: 1. Assess the resident. This assessment evaluation could include, but is not limited to the following. a. Vital signs, oxygen saturation, blood glucose level. 5. Monitor the resident's condition frequently until stable or transported to a higher level of care, if needed. 7. Update plan of care as needed. On [DATE], Surveyor reviewed R25's medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not thoroughly investigate a fall to ensure the environment was as free of accident hazards as possible for 1 Resident (R) (R1) of 5 sampled residents. R1 was overheard by a nurse reporting a fall to a family member on 8/18/23. The facility did not complete a thorough investigation to determine a root cause analysis or complete staff education to minimize the likelihood of future falls. Findings include: The facility's Fall Prevention and Management Guidelines, with a review date of 11/08/22, indicated: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls .Definition-A fall is an event in which an individual unintentionally comes to rest on the ground, floor or other level .The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere .7. When any resident experiences a fall, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-26 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review, the facility failed to ensure the resident representative (RR) was notified timely of a fall for 1 (R173) of 1 resident reviewed for notification of change. Findings included: The facility's policy, titled, Change of Condition of the Resident, revised on 09/20/2022, indicated, A facility should immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status; or a need to alter treatment significantly. The policy further revealed When a resident presents with a possible change of condition, after a fall or other possible injury, trauma, or noted changes in mental or physical functioning the facility should 4. Notify resident's family/responsible party as applicable…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-26 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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, record review, and facility policy review, it was determined the facility failed to revise the comprehensive care plan to address a resident's ability to safely smoke without supervision for 1 (R9) of 1 sampled resident reviewed for smoking. Findings included: A review of a facility policy titled, Smoking Policy, revised 07/14/2022, revealed, Risk factors identified through the assessment process shall be used in development of the plan of care. R9 was admitted with diagnoses that included closed fracture with routine healing, abnormalities of gait and mobility, and post-polio syndrome. R9's Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Per the MDS, R9 had no impairment in range of motion of the upper extremities. A review of a Nicotine Assessment, dated 12/20/2022, revealed R9 was independent with smoking and required no supervision to use tobacco/nicotine products.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-26 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview, record review, and facility policy review, it was determined that the facility failed to ensure a medication error rate of less than 5% for 2 (Residents #3 and #13) of 4 residents observed for medication administration. Specifically, there were two errors out of 31 opportunities, which yielded a medication error rate of 6.45%. Findings included: A review of a facility policy titled, Medication Administration General Guidelines, dated 01/2021, specified, Medications are administered in accordance with written orders of the prescriber. Example 1 R3 was admitted with diagnoses that included hypertensive heart disease with heart failure and primary pulmonary hypertension. R3 had a physician's order dated 01/04/2023 for lisinopril tablet, 10 milligram (mg). The directions were to administer 10 mg by mouth once daily for hypertension. A medication pass observation was conducted on 01/24/2023 at 8:03 AM with LPN D (Licensed Practical Nurse) on the 200 Hall. LPN D administered lisinopril 5 mg, one tablet to R3 instead of 10 mg as ordered by the physician.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure hand hygiene was performed between dirty and clean tasks during catheter care to prevent potential infection for 1 (R1) of 2 sampled residents reviewed for urinary catheters/urinary tract infection. Findings included: A review of a facility policy titled, Hand Hygiene, dated 11/02/2022, specified, Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. The Hand Hygiene Table indicated hand hygiene with either soap and water or alcohol based hand rub would be performed after handling contaminated objects, after handling items potentially contaminated with blood, body fluids, secretions, or excretions, and when moving from a contaminated body site to a clean body site during care. R1 has diagnoses of paraplegia (paralysis of the lower body), anoxic (absence of oxygen) brain damage and neuromuscular dysfunction…
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.
- No harm found · C2024-09-12 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility did not ensure the nurse staffing posting accurately reflected the number of nursing staff working in the facility. This had the potential to affect all 23 residents who resided in the facility on 4/14/24. The nurse staffing posting and payroll record did not accurately reflect the actual nursing staff who worked on 4/14/24. Findings include: The facility's Nurse Staffing Posting Information policy, with a revision date of 10/13/22, indicates: It is the policy of the facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time .1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: .d. The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for the resident care per shift: .i. Registered Nurses; ii. Licensed Practical Nurses/Licensed Vocational Nurses; iii. Certified Nursing Aides. 2. The facility will post the Nurse Staffing Sheet daily…
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.
- No harm found · Ccited before2024-02-06 · tag F0623 — widespreadProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility did not ensure a resident or their representative was provided a written transfer notice and did not ensure the State Long Term Care Ombudsman was notified when 2 Residents (R) (R10 and R17) of 2 residents transferred to the hospital. R10 was transferred to the hospital on 1/9/24. The facility did not provide R10 or R10's representative with a written transfer notice and did not notify the Ombudsman of R10's transfer. R17 was transferred to the hospital on 4/21/23, 6/29/23, and 10/5/23. The facility did not provide R17 or R17's representative with a written transfer notice and did not notify the Ombudsman of R17's transfers. Findings include: The facility's Transfer Discharge policy, dated 7/15/22, indicates: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except as initiated by the resident, necessary for the health and safety of the resident or other individuals are endangered, or as otherwise permitted by applicable law…
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.
- No harm found · Ccited before2024-02-06 · tag F0625 — widespreadNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility did not ensure written bedhold policy information was provided for 2 Residents (R) (R10 and R17) of 2 residents who transferred to the hospital. R10 was transferred to the hospital on 1/9/24. The facility did not provide R10 or R10's representative with a written bedhold notice. R17 was transferred to the hospital on 4/21/23, 6/29/23, and 10/5/23. The facility did not provide R17 or R17's representative with a written bedhold notice. Findings include: The facility's Transfer Discharge policy, dated 7/15/22, indicates: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except as initiated by the resident, necessary for the health and safety of the resident or other individuals are endangered, or as otherwise permitted by applicable law .Emergency Transfer/Discharges-Initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified): a. Obtain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$17,170 in federal fines across 1 penalty.
- $17,170 — penalty dated 2024-09-12
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 NORTH SHORE HEALTHCARE — 59 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.7 | -0.7 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 3 of 5 | 3.4 | -0.4 vs chain |
| Quality measures | 2 of 5 | 2.5 | -0.5 vs chain |
The other 58 homes this chain runs (chain average 2.7★, per CMS)
Showing 40 of 58; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NSHF OPERATIONS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/24/2017 |
| MILLS, DAVID | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 20% | since 06/29/2017 |
| BAUMANN, TROY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | — | since 06/29/2017 |
| HOEHN, JEFFREY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 06/29/2017 |
| NORTH SHORE HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2017 |
CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $141K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525586. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-12, 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.