Prescott Nursing And Rehab Community
1505 Orrin Rd, Prescott, WI 54021 · For profit - Corporation · 65 certified beds · (715) 262-5661 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $30,654 in federal fines (most recent 2025-04-07)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 15.1% | 16.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 7.0% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 5.3% | 2.7% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.1% | 5.7% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.9% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.4% | 18.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 6.3% | 16.9% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 93.5% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.0% | 5.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 1.1% | 24.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.4% | 15.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.6% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 96.4% | 82.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 29.6% | 23.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.9% | 15.5% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 4.26 | 1.66 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.72 | 2.29 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
38.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.5% 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 39 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% 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 | 38.5%CMS range 25.0–50.2 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 7.2–15.1 | 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 | 61.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 59.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 71.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.9%CMS range 3.8–15.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.24 | 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 65 beds and averages 38.1 residents a day — about 59% occupied, or roughly 27 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 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 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 3.31 hrs/resident/day on weekends vs 3.66 on weekdays — 10% thinner on weekends. RN hours go from 0.85 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 1 administrator has left in the past year.
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.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-04-07 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 interview and record review, the facility did not ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident (R) reviewed. (R33) R33 was not given enteral feeding nutrition as ordered; instead R33 received twice as much as ordered resulting in vomiting and aspiration, requiring suctioning and transfer to hospital on [DATE] where R33 expired on [DATE]. The facility's failure to properly monitor, assess, and correctly follow physician (MD) orders and treatments for enteral feeding resulted in resident receiving twice as much enteral feeding as ordered and created a finding of Immediate Jeopardy (IJ) that began on [DATE]. The state agency notified Nursing Home Administrator (NHA) A of the immediate jeopardy on [DATE] at 3:00 PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a level D (potential for harm/isolated) as the facility continues to implement its action plan. This 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 · D2026-05-13 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 1 of 5 residents (R) reviewed were free from chemical restraints. (R21)R21 was prescribed a hypnotic medication. There is no indication nonpharmacological interventions were tried prior to initiating the medication. The facility did not complete a sleep assessment, care plan, or monitor R21's sleep. R21 denied insomnia or history of sleep concerns. R21 is not informed that R21 is taking a psychotropic for sleep.Findings:R21 was admitted to the facility on [DATE] and has diagnoses including bipolar disorder, obstructive sleep apnea (adult) (pediatric), acute and chronic respiratory failure with hypoxia, asthma, manic episode, unspecified mood (affective) disorder, and anxiety disorder.R21's Minimum Data Set (MDS) assessment, dated 5/1/26, indicated R21 is dependent for assistance for all transfers and assistance with position changing. R21 can perform most activities of daily living with assistance of setting up the task. R21's Brief Interview of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the residents remain free of possible accidental hazards. Facility did not determine the correct mechanical full body lift (Hoyer) sling size and ensure staff were applying the correct size Hoyer sling to prevent accidents for 3 of 7 residents (R) reviewed. (R7, R37, R44). Facility developed a plan of care for R37 that listed the use of an xl (x-[NAME] large) Hoyer sling when a large sling should be used per manufacturer's guidelines. Certified Nursing Assistants (CNAs) used a medium Hoyer sling to transfer R37. Facility developed a plan of care for R44 that listed use of an xl sling when a large Hoyer sling should be used per manufacturer's guidelines. CNAs used a medium Hoyer sling to transfer R44. Facility developed a plan of care for R7 that listed use of an xl sling when a large Hoyer sling should be used per manufacturer's guidelines.Findings include:The Direct Supply Slings manufacturer's guidelines, no date, states, 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 · Dcited before2026-05-13 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 received the appropriate treatment and services to prevent complications for 1 of 1 resident (R) receiving nutrition through tube feedings (enteral nutrition) (R26).The facility did not ensure standards of practice were conducted by ensuring proper gastrostomy tube (G-tube) placement before administering medications via G-tube.The facility policy titled, Care and Treatment of Feeding Tubes, last reviewed 04/03/25 states under the section of Policy Explanation and Compliance Guidelines, .6.licensed nurses, will monitor and check that the feeding tube is in the right location (a). Tube placement will be verified before beginning a feeding and before administering medications.On 05/12/26, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] with a diagnosis of placement of a gastrostomy tube following surgery for right hemicolectomy.R26's admission Minimum Data Set (MDS) assessment, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-13 · 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, and record review, the facility did not provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 14 residents. (R4 and R7)-Certified Nursing Assistant (CNA) E did not place barrier between floor and graduate when emptying R4's Foley catheter bag.-CNA D did not sanitize the mechanical lift after transferring R6, nor prior to using mechanical lift to transfer R7. CNA D and CNA E used the EZ stand lift for R4's transfer from bed to wheelchair and did not sanitize after use. The facility policy titled, Cleaning/Disinfecting Resident-Care items and Equipment, reviewed on 01/20225 states, . Reusable items are cleaned and disinfected between residents . The facility procedure titled, Emptying a Urinary Drainage Bag Competency, states, . 4. Place a paper towel on floor next to the drainage bag. 5. Place graduate collection container on top of paper towel. Wisconsin Nursing Assistant Curriculum, Copyright © 2023 by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-07 · 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, record review and interview, the facility did not prepare, store or distribute foods in a sanitary manner. The facility practices had the potential to affect all 29 residents. Kitchen staff did not complete monitoring of sanitation chemicals used to clean kitchen surfaces. Food items stored in the resident refrigerator on the unit were beyond use by dates. This is evidenced by: Facility policy titled, Sanitation Terminology, with a revised date of 01/25, states in part: Quaternary Solutions: a)Use of quat for food contact surfaces bucket: Add quat to water and test concentration in the water by using test strip. It should read 150-400 PPM on the chart. Facility dietary guideline posted on resident refrigerator titled, Unit Fridge, with no date, states in part: Sandwiches made from dietary expires 3 days after preparation. Example 1 On 04/01/25 at 7:44 AM, Surveyor observed red sanitation bucket with a rag inside. No log sheets were observed in kitchen area to document the level of chemicals used in the sanitation bucket. On 04/01/25, Surveyor reviewed 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 before2025-04-07 · 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, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 29 residents (R). -The facility did not have an infection surveillance process in place for a GI outbreak in March 2025. -Staff did not follow Enhanced Barrier Precautions (EBP) of wearing personal protective equipment (PPE) when providing IV medication administration for R236, when providing catheter care and positioning for R22, and when providing resident cares for R11. Findings include: Example 1 Surveyor reviewed Infection Control (IC) surveillance logs and found the facility identified the facility had an outbreak of Gastrointestinal virus labeled the Norovirus in March 2025, which affected 14 residents and 11 staff members. Surveyor reviewed surveillance logs for March 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 · E2025-04-07 · tag F0623 — patternProvide 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 interview and record review, the facility did ensure notification in writing to the resident or resident representative, and the Office of the State Long-Term Care Ombudsman of residents' transfer or discharge from facility per regulation requirements. The facility practice affected 5 out of 5 residents (R) reviewed for the Office of the State Long-Term Ombudsman notice (R11, R1, R33, R22, R2), and 4 of 5 residents reviewed for transfer notice (R11, R1, R33, R22). Findings include: Facility policy titled, Resident Transfers and Discharge Notification, with a revised date of 04/20/20, states in part: Notice of Transfer or Discharge and Ombudsman Notification: For facility-initiated transfer or discharge of a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand .The facility must send a copy of the notice of transfer or discharge to the representative of 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 · D2025-04-07 · 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 and record reviews, the facility did not notify provider as indicated for blood sugars outside of desired parameters for 1 of 12 residents, (R) R7, reviewed. This is evidenced by: Facility policy titled, Notification of Change, with a reviewed date of 01/2025 states in part: The resident's physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer or death .Some physicians may require different notification parameters for conditions such as blood glucose or other conditions. Please follow the physician's order in these cases. R7 was admitted to the facility on [DATE] with a pertinent diagnosis of diabetes mellitus type 2. R7's admission Minimum Data Set (MDS) assessment dated [DATE] noted medication administration of insulin injections and receives hemodialysis. R7's orders: 02/25/25: Insulin lispro 100 unit/ml give per sliding scale three times daily. Per sliding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-07 · 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 interview and record review, the facility did not provide written notice of bed-hold policy to the resident or their representative for 1 of 5 residents (R) reviewed for hospitalization. (R22) This is evidenced by: Facility's policy titled Bed Hold with the reviewed date of 01/25, documented in part, 1. The facility Social Worker or designee will provide a copy of the bed hold policy to the resident and/or the resident representative at the time of admission and again prior to a transfer due to hospitalization or therapeutic leave. The signed copies will be maintained in the resident's financial or personal file .3. In the event of an emergency transfer to a hospital, the facility social worker or designee will attempt to contact the resident or resident representative within 24 hours of the transfer and determine whether to hold the resident's bed. Documentation of the bed hold decision will be completed in the resident's medical record. The facility will document multiple attempts if necessary 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 · D2025-04-07 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
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 implement an effective discharge plan with a focus on identifying resident's need and an effective transition to post discharge care for 1 of 1 resident (R) who were ordered for discharge from the facility, R26. Findings include: Facility policy titled, Discharge/Transition Discharge Planning Process, dated reviewed on 01/2025 states in part, .Standard: All residents will have a discharge plan that supports a smooth transition to home or to the next care setting. The foundation of the plan will be developed for most residents at the time of admission. Procedure: 1. Social Services will facilitate the formulation of the discharge/transitional plan with resident, family, and interdisciplinary team. 2. Social Services will interview the resident and family after admission to determine their discharge and wellness goals. Form 3.6.A 3. The Social worker will develop the resident's initial discharge planning care plan to include the goals and plans. The care…
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 15 citations
- Potential for harm · Dcited before2025-04-07 · 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, interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice for 2 of 12 residents (R) (R1, R24) reviewed. Staff did not remove sutures per provider orders for R24 or implement hospital discharge orders upon readmission for R24. Facility did not enter and administer physician orders for R1. Example 1 Findings include: Facility policy titled, Skin Care, dated reviewed on 06/2019 states in part, .1. Nurses will complete a skin body assessment upon admission/readmission, then weekly, and as needed. 2. Certified Nursing Assistant will inspect resident skin during bathing activities and report any irregularities or concerns to the licensed nurse evaluation. 3. Interventions will be implemented, and care planned to reduce risk of skin impairment. 4. Non-pressure related skin impairment will be assessed and documented upon admission, readmission, upon discovery, and weekly thereafter. Assessment may include…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility did not ensure 2 of 3 residents (R24 and R11) reviewed for high risk of Pressure Injury (PI) development received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. - R24 is high risk for the development of PIs and has a stage 3 PI to the right heel. R24 was observed for 2 hours and 58 minutes in which she was lying in bed without staff offering or attempting to reposition and heels were not elevated as ordered. -Staff did not perform proper hand hygiene when applying topical prescriptions to R24's wound bed during wound dressing change. -Staff did not sanitize bedside tables for R24 and R11 during wound dressing change. This is evidenced by: Example 1 According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause 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 · D2025-04-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that services for a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, for 1 of 1 resident (R) R14 reviewed for respiratory assessment related to medication administration. R14 was administered a nebulizer treatment without a lung assessment completed prior to and after treatment. Evidenced by: Facility's policy titled Med Pass read in part, M. Nebulizer treatment administration.6. Assess pulse, respiratory rate, breath sounds, pulse oximetry before beginning treatment .12. Monitor patient's pulse, respiratory rate, breath sounds and pulse oximetry post treatment and as ordered by physician . According to the National Library of Medicine (2021), the standard of nursing care expected with small volume nebulizer treatment includes: .respiratory assessment pre/post treatment, respiratory rate, heart rate, and oxygen saturation. After treatment, the patient should 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.
- Potential for harm · D2025-04-07 · 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 observations, interviews and record reviews, the facility failed to provide pharmaceutical services related to the accurate administration of steroid inhaler to meet the needs for 1 of 1 resident (R) reviewed, R14. This is evidenced by: Facility's policy titled Med Pass read in part, M. Nebulizer treatment administration.14. If inhaled medication included steroids, have patient rinse mouth and gargle with warm water after treatment . R14 was admitted to the facility on [DATE] with a pertinent diagnosis of chronic respiratory failure. R14's orders included: 01/30/25: Budesonide suspension for nebulization; 0.5 mg/2 ml; amt: 0.5 mg; inhalation Special Instructions: Administer 1 neb twice per day for shortness of breath twice per day. Please rinse mouth with water after use. Do not swallow. On 04/01/25 at 7:25 AM, Surveyor observed Licensed Practical Nurse (LPN) D poured Budesonide nebulizer suspension into R14's nebulizer canister on bedside table and gave mouthpiece to R14. LPN D turned on machine 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 · D2025-04-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility did not ensure they were monitoring the effectiveness of psychotropic drugs for 2 of 4 residents (R) (R14, R21). The facility did not complete behavior monitoring as outlined in the comprehensive care plan to determine adequate indication for use of antidepressant medications (duloxetine and buproprion) for R14. R21 receives trazodone, an antidepressant medication, for sleep with no adequate indication for use and no sleep hygiene care plan with non-pharmacological interventions to promote sleep. This is evidenced by: The facility policy, titled Behavioral Health Services, dated 1/2025, states: 7. Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions. Examples of individualized, non pharmacological interventions d. Indivdualizing sleep and dining routines The facility policy, titled Pyschotropic Medication Use, dated 1/2025,…
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 before2024-02-14 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 39 residents (R). The facility had a sick employee with respiratory symptoms on duty delivering direct resident care. Improper hand hygiene was observed during wound care and personal care for R1 and R5. Facility laundry services had dirty linens on the floor and personal items were stored in a clean linen area. Staff carried soiled linens in the hallway without containing them in a plastic bag. Findings include: Surveyor requested and reviewed the facility policy titled Employee Illness Surveillance Practices dated last review January 2024. The policy reads in part: .#3. In the event an employee calls in due to illness it will be recorded on the employee call-in form. Illness symptoms will be recorded on the form and reported to the infection control…
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 · D2024-02-14 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, the facility did not close the privacy curtain to provide privacy during personal care to the resident's abdominal/groin area for 1 of 1 sampled resident (R18). This is evidenced by: R18 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus with diabetic neuropathy, unspecified, dysphagia, oral phase, pressure ulcer of sacral region, stage 2, pressure ulcer of left buttock, stage 2, retention of urine, and unspecified, muscle weakness (generalized). R18's Minimum Data Set assessment, dated 11/12/23, indicates R18 has a Brief Interview for Mental Status (BIMS) score of 99 (severe cognitive impairment)-resident unable to complete interview. On 02/12/24 at 9:15 AM, Surveyor observed R18. Surveyor observed R18 in bed lying on his back with the head of the bed rolled up. Surveyor attempted to interview R18, with no response. On 02/13/24 at 7:22 AM, Surveyor observed Certified Nursing Assistant (CNA) E and Director of Nursing (DON) B providing activities…
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 · D2024-02-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility did not ensure to develop and implement a comprehensive individualized care plan to meet the needs of the residents (R). R18's care plan was not developed for intermittent urinary catheterization and for incontinence of bladder and bowel. This occurred for 1 of 13 sampled residents (R18). This is evidenced by: R18 was admitted to the facility on [DATE] and has a diagnosis of retention of urine. R18's Minimum Data Set assessment, dated 11/12/23, Section H: Bowel and bladder indicates R18 is intermittingly catheterized, is frequently incontinent of bladder and continent of bowel. Currently R18 is not continent of bowel. On 02/13/24 at 2:42 PM, Surveyor reviewed R18's current comprehensive care plan. R18 did not have a care plan for intermittent urinary catheterization or urinary and bowel incontinence. R18 did have a care plan with the start date of 10/07/23 for an indwelling Foley catheter. R18 does not have an indwelling Foley catheter. On 02/13/24…
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 · D2024-02-14 · 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 record review and interview, the facility did not review and revise the fall comprehensive care plan for 1 of 3 sampled residents (R) R239. Findings include: Record review identified that R239 was admitted to the facility on [DATE]. R239's diagnoses included, in part, displaced supracondylar fracture without intercondylar extension of the lower end of the right femur, subsequent encounter for closed fracture with routine healing, bilateral artificial knee, joint pain in the right knee, muscle weakness, opioid use, anxiety disorder, and asthma. R239's Brief Interview for Mental Status score (BIMS) was deemed 15, indicating cognition intact. Review of R239's record identified the following baseline care plan dated 01/25/24 indicated: R239 is the assist of one with gait belt and two-wheel walker for all transfers, assist of one with lower body dressing and toileting . Review of R239's comprehensive fall care plan last revised on 01/25/24 indicated: R239 is at risk for falls and subsequent injury related 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 · D2024-02-14 · tag F0659 — isolatedProvide care by qualified persons according to each resident's written plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility did not ensure prescription medications were administered by qualified staff. Surveyor observed Certified Nursing Assistant apply prescribed Nystatin powder to a resident's (R) skin for 1 of 1 observation. (R5) Findings include: On 02/13/24 at 10:00 AM, Surveyor observed Certified Nursing Assistant (CNA) C wash up and provide morning cares for R5. After CNA C washed and dried R5's skin, CNA C applied powder under R5's breasts. Surveyor asked CNA C what powder was applied to R5's skin. CNA C replied, nystatin powder. Surveyor visualized bottle and noted a prescription label with R5's name, the name of the medication nystatin powder, and instructions for administration. On 02/14/24 at 7:29 AM, Surveyor interviewed CNA E and asked if they ever applied any powder to R5's skin when providing morning cares. CNA E stated if R5 had redness under skin folds, there was a powder that CNA E put on after washing R5. CNA E did not know the name of the powder. On 02/14/24 at 8:21 AM, Surveyor interviewed R5 and asked what the staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility did not ensure that 3 of 6 sampled residents (R) who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. (R1, R3, and R6) R1 did not receive regular assistance with toileting or personal care. R3 did not receive regular assistance with personal care or repositioning every 2 hours as care planned. R6 did not receive regular assistance with turning and repositioning or bathing and personal cares Findings include: Example 1 R1 was admitted on [DATE]. R1 had the following diagnoses, in part: pneumonia, congestive heart failure, atrial fibrillation, type 2 diabetes mellitus with diabetic neuropathy, muscle weakness, urinary tract infection, overactive bladder, mixed incontinence, intervertebral disc disorder with radiculopathy lumbar region, and gout. R1's admission Minimum Data Set (MDS) assessment dated [DATE] indicates Brief Interview for Mental Status…
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 before2024-02-14 · 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, interview and record review, the facility did not provide care and services in accordance with professional standards of practice for 3 of 3 residents (R). (R18, R1, R3). R18 did not have cares provided as care planned and had reoccurring moisture associated skin damage (MASD) to the buttocks. The facility did not ensure R1 had heart failure assessed. R3 did not receive skin care to prevent breakdown to the right hand. Findings: Example 1 Incontinence care, repositioning, compression stockings R18 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus with diabetic neuropathy, unspecified, dysphagia, oral phase, pressure ulcer of sacral region, stage 2, pressure ulcer of left buttock, stage 2, retention of urine, and unspecified, muscle weakness (generalized). R18's Minimum Data Set assessment, dated 11/12/23, indicates R18 has a Brief Interview for Mental Status Score (BIMS) of 99 (severe cognitive impairment)-resident unable to complete interview.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not ensure residents with limited range of motion (ROM) received services to maintain or prevent further reduction in ROM for 1 of 1 resident (R) R3 reviewed. This is evidenced by: R3 was admitted to the facility on [DATE] with diagnoses including, in part, Lennox-gastaut syndrome (LGS), dysphagia, heart failure, and hypertension. Provider note on 02/15/24 states in part, That adults with LGS have multiple types of seizures that vary among individuals. Different kinds of seizures include but are not limited to tonic seizures (stiffening of the body, upward eye gaze, dilated pupils, and altered breathing patterns), atypical absences (staring spells), atonic seizures (brief loss of muscle tone, which could cause abrupt falls), myoclonic seizures (sudden muscle jerks), and generalized tonic-clonic seizures (muscle stiffness and rhythmic jerking.) [R3] may appear to have significant contractures but are a manifestation of her seizure disorder.…
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 before2024-02-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the environment remained free of hazards for 1 of 1 Resident (R) who smokes. Findings: Facility policy titled, Smoking Policy, last reviewed 01/2024, states in part: .4.m Residents are not permitted to have lighters or other smoking paraphernalia on their person during non-smoking times. This includes both safe & unsafe smokers . R32 was admitted on [DATE] with a Brief Interview of Mental Status (BIMS) of 14 indicating intact cognition. A 'Safe Smoking Assessment' was completed on R32 on 01/17/24 that revealed the resident is a safe smoker and is independent. Care plan titled, At risk for injury related to smoking, included: ~resident was assessed as being safe and independent. ~resident will remain compliant with center's smoking policy. ~no smoking materials kept by resident. ~report any non-compliant or viewed unsafe practices. ~maintain all smoking materials at the nurses station or other designated area. On 02/13/24 at 10:53 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure 1 of 1 sampled resident (R18) maintained acceptable parameters of nutrition. R18 has experienced a continual weight loss, meal assistance or alternatives to meals were not provided, daily weights were not completed. The last updated intervention for nutrition was 1/11/24. This is evidenced by: R18 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus with diabetic neuropathy, unspecified, dysphagia, oral phase, pressure ulcer of sacral region, stage 2, pressure ulcer of left buttock, stage 2, retention of urine, and unspecified, muscle weakness (generalized). history of cancer in prostate, UTI recurrent with hydronephrosis. R18's Minimum Data Set (MDS) assessment, dated 11/12/23, indicates R18 has a Brief Interview for Mental Status Score (BIMS) of 99 (severe cognitive impairment)-resident unable to complete interview. MDS Section GG: Self Care shows R18 requires set up or clean up assistance…
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
$30,654 in federal fines across 1 penalty.
- $30,654 — penalty dated 2025-04-07
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 ATRIUM CENTERS — 26 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 | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 4 of 5 | 3.4 | +0.6 vs chain |
| Quality measures | 2 of 5 | 3.7 | -1.7 vs chain |
The other 25 homes this chain runs (chain average 3.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BAILEY, ESSEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 74% | since 12/01/2007 |
| FINNEY, DONALD | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 25% | since 08/01/2003 |
| LOCKHART, DENNIS | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 08/01/2003 |
| SCHMIDT, ROBERT | Individual | W-2 MANAGING EMPLOYEE | — | since 01/01/2008 |
| SWEDBERG, KARL | Individual | W-2 MANAGING EMPLOYEE | — | since 09/25/2017 |
| ATRIUM CENTERS MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2007 |
| ORION OPERATING SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2007 |
CMS files one row per role, so the 8 rows in the source record cover these 7 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 $545K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525398. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-13, 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 →
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