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Kinnic Health And Rehabilitation Center

1663 E Division St, River Falls, WI 54022 · For profit - Limited Liability company · 68 certified beds · (715) 426-6000 Medicare & Medicaid certified

Call the home — (715) 426-6000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 2025
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 22% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1687 E Division St · (715) 425-6701 · Call to confirm hours
Pharmacy
1047 N Main St · (715) 426-4089 · Call to confirm hours
Grocery
126 S Main St · (715) 425-7971 · Call to confirm hours
Park
999 Hanson Dr · Typically dawn to dusk
Place of worship
1663 E Division St · (715) 821-4207

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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.3%16.1%15.4%better
Long-stay residents who lose too much weight4.8%5.1%5.4%better
Long-stay residents with a catheter left in their bladder0.0%2.1%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%2.7%2.0%better
Long-stay residents with depressive symptoms1.5%5.7%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.4%3.3%3.3%worse
Long-stay residents whose ability to walk worsened9.8%18.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.6%16.9%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers2.6%5.0%4.7%better
Long-stay residents with worsening bladder/bowel control27.9%24.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table24.1%15.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.5%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%82.2%79.4%better
Short-stay residents rehospitalized after admission15.1%23.1%22.6%better
Short-stay residents with an outpatient ER visit11.1%15.5%12.0%typical
Long-stay hospitalizations per 1,000 resident days0.871.661.67better
Long-stay outpatient ER visits per 1,000 resident days3.652.291.80worse

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.

49.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 84 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.1%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
56.1%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 56.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 98 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.1%CMS range 40.0–57.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.3–14.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge56.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge54.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge36.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.9%CMS range 3.2–12.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.151.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.96
RN hours/ resident / day
0.64
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.82
Total nurse hours/ resident / day
0.79
RN hoursweekends
36.8%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 68 beds and averages 46.2 residents a day — about 68% occupied, or roughly 22 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 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.96 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 3.49 hrs/resident/day on weekends vs 3.95 on weekdays — 12% thinner on weekends. RN hours go from 1.02 to 0.79 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.

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

Inspection trend

12
deficiencies at the latest standard inspection (2025-06-11)
4
at the previous standard inspection (2024-05-02)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · F2025-06-30 · tag F0727 — failed to provide required RN coverage — widespread
    Have 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 interviews, the facility did not ensure full time Director of Nursing (DON) coverage. This has the potential to affect all 48 residents. Former DON C resigned effective 06/17/25. The facility did not have a full time DON from 6/17 - 6/30/25. This is evidenced by: On 06/30/25 at 8:15 AM, Surveyors entered the facility and requested to meet with the Nursing Home Administrator (NHA) A or DON B. Social Worker Assistant (SWA) D stated DON B works part-time Tuesday, Wednesday, Thursday and the Assistant Director of Nursing (ADON) E is on vacation. On 06/30/25 at 4:05 PM, Surveyor interviewed NHA A asking about a full-time 40 hour a week DON. NHA A stated DON C left on 06/17/25 with no advance notice and DON B was initially hired to start in August in full-time status. DON B agreed to start on 06/17/25 part-time until August, when DON B could work full time. NHA A stated ADON E is here full-time and is on vacation this week. NHA A stated ADON E is a Licensed Practical Nurse (LPN). Surveyor asked NHA A if there was a plan of an interim DON to be full-time 40 hours a week. NHA A…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 interview and record review, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice for 1 out of 1 resident sampled, R1. The facility did not adequately monitor and assess R1's ventriculoperitoneal (VP) shunt having the potential to result in serious complications. This is evidenced by: According to the National Institute of Health, VP shunts should be regularly monitored and assessed for complications. Signs and symptoms of shunt malfunction/infection include headache, lethargy, diplopia, nausea, vomiting, seizure, irritability, fever, and neck rigidity. Shunt system has to be assessed manually for proper function and visible for evidence of redness or swelling along the shunt tubing. Additional assessment of abdomen should be completed regularly monitoring for abdominal cerebrospinal fluid (CSF) that may result in ascites, pseudocysts, or inguinal hernia. R1 was admitted to the facility on [DATE], with pertinent diagnoses of congenital…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 3 of 3 residents (R), R2, R5, and R1 reviewed. R2, R5 and R1 had fallen; the facility did not initiate immediate intervention to prevent future falls, investigate the root cause of the fall and review and revise care plan fall interventions. This is evidenced by: Facility policy titled, Falls Management, with no initiated or reviewed date, states in part: Policy: The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. Residents are assessed for fall risk factors. The interdisciplinary team works with the residents and family to identify and implement appropriate interventions to reduce the risk of falls or injuries .Procedure: 3. Discuss goals and interventions with resident/family…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-30 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 licensed nurses had the specific competencies and skill set necessary to care for a resident's needs, as identified through resident assessment, and described in the plan of care, for 1 of 1 resident (R) reviewed for ventriculoperitoneal (VP) shunt care, R1. The facility did not provide training and education to licensed staff to ensure competency in the care of R1's VP shunt. This is evidenced by: Facility Assessment, dated 08/07/24, states in part: .Competencies: Kinnic considered the .clinical characteristics of the resident population to determine the skills and competencies required to meet our resident needs. We identified four categories of competencies: knowledge, assessment, pharmacological/treatment/care considerations, and technical/hands-on skills. Refer to the worksheet Facility Education/Staff Competencies Necessary to Care for Resident Population. The worksheet identifies which staff require certain competencies and skill sets, 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-06-11 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews, the facility did not ensure Certified Nursing Assistant (CNA) received a performance review every 12 months for three of three CNAs reviewed (CNA C, CNA D, CNA P). The facility failed to have a system in place to ensure that performance reviews were being done for any of the facility CNAs. This had the potential to affect all 49 residents residing in the facility. This is evidenced by: On 06/10/25, a sample of CNAs employed by the facility was selected for review for the completion of annual performance reviews. The facility provided the following information: CNA C has been employed at the facility since 12/15/20. An annual performance review could not be located. CNA D has been employed at the facility since 09/2019. An annual performance review could not be located. CNA P has been employed at the facility since 12/06/21. An annual performance review could not be located. On 06/10/25 at 8:15 AM, Surveyor interviewed Nursing Home Administrator (NHA) A about yearly performance evaluations on staff. NHA A was not able to find yearly…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-06-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and policy review, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. Staff were observed not allowing thermometer to dry prior to checking temperatures of food items and not inverting mixer and bowls in storage. This had the potential to affect all 49 residents in the facility. Findings: Example 1 On 06/08/25 at 10:45 AM, Surveyor conducted the initial tour of kitchen with [NAME] T who has been on staff 12 years. Surveyor observed the Kitchen Aide mixer on the counter with bowl under it that was not inverted. Surveyor also observed large industrial size mixer in kitchen with bowl stored under it which was not inverted. Neither of the mixers were covered. Surveyor interviewed [NAME] T and asked what the normal way is to store when not in use. [NAME] T stated both mixers are used 2-3 times a week and stored uncovered and not inverted when not in use. Surveyor observed a rack of large bowls and pans that were not inverted. [NAME] T stated that is normal to store the rack of dishes…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-06-11 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system from 7/1/24 - 3/31/25 which triggered excessively low weekend staffing. This has the potential to affect all 49 residents residing in the facility. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.1.2 Submission Timelines…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0555 — isolated
    Honor the resident's right to choose his or her attending physician.
    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 allow resident the right to choose physicians/treatment options for 1 of 18 residents (R) reviewed. (R4). -Facility denied R4 the right to follow up with the wound provider of choice. R4 wanted to follow up with the VA wound provider and not the facility in-house provider. -R4 was seen by provider of choice and when returned to the facility with new orders, staff told R4 the facility will not do those treatments and had the attending physician discontinue the orders. Findings include: According to the Board on Aging and Long-term Care, residents have a right to self-determination which includes, in part: - Offered choices and allowed to participate in decisions important to you. - Expect a reasonable accommodation of your needs and preferences. - Participate in the planning of your care and services, and to receive care and services in a way that respects your personal and cultural wishes. - Request, discontinue or decline care 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0582 — isolated
    Give 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

    Based on staff interview and record review, the facility did not provide Advanced Beneficiary Notice (ABN) of non-coverage for residents (R) whose Medicare Part A coverage was discontinued with benefit days remaining for 2 of 3 residents (R) reviewed. (R43, R33) R43 and R33 were discharged from Medicare Part A services with benefit days remaining and remained in the facility. The facility did not provide an ABN informing the residents of their liability once Medicare coverage ended. Findings include: On 06/09/25 at approximately 9:00 a.m., Surveyor reviewed documents provided by the facility for residents who had been discharged from Medicare Part A with benefit days remaining. R43 start of services: 4/14/25, Last Covered Date (LCD): 6/02/25, notice of non-coverage 5/29, with no notice of patient liability provided to R43. R43 remained in the building. R33 start of services: 4/01/25, LCD: 5/30/25, notice of non-coverage 5/27/25 and no notice of liability was provided to R33. R33 remained in the building. On 06/09/25 at 2:13 PM, Surveyor interviewed Business Office Manager (BOM) I…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for 1 of 18 residents (R) reviewed for abuse (R98). The facility did not ensure all staff were trained on the abuse policy, did not complete audits of staff to protect residents from abuse, or ensure staff knowledge of the abuse and reporting policy, and did not have a quality improvement plan to prevent further verbal abuse. This is evidenced by: Facility's policy titled Abuse, Neglect and Exploitation with no date implemented, read in part, II. Employee Training, B. Existing staff will receive annual education through planned in-services and as needed .III. Prevention of Abuse, Neglect and Exploitation, H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors .VIII. Coordination with QAPI, A. The facility has written policies and procedure that define how staff will communicate and coordinate situations of abuse, neglect,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2025-06-11 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not implement policies and procedures for ensuring the reporting of verbal abuse in accordance with section 1150B of the Act when an allegation of verbal abuse was not reported immediately but no later than 2 hours to the administrator and local law enforcement in accordance with state law through established procedures for 1 of 2 residents (R) reviewed (R98). This is evidenced by: Facility's policy titled Abuse, Neglect and Exploitation with no date implemented, read in part, VII. Reporting/Response, 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury R98 was admitted to the facility on [DATE] with hospice services. R98's diagnoses included…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure residents (R) received proper treatment and assistive devices to maintain hearing abilities. This affected 1 of 3 residents reviewed who needed hearing aids (R28). R28's hearing aid was broken and not replaced for several months. R28 continues with no left ear hearing aid, which impacts R28's ability to adequately hear. Findings Include: R28 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, primary open-angle glaucoma right eye-moderate state, low vision right eye, blindness left eye, disorientation-unspecified, and cognitive communication deficit. R28's Minimum Data Set (MDS) assessment, dated 3/31/25, indicated R28's Brief Interview for Mental Status (BIMS) score is 9/15, which means mild cognitive impairment. R28 requires supervision or touching assistance with eating, substantial/maximal assistance with toileting hygiene, shower,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 that residents with a suprapubic catheter received the appropriate care and services for 1 of 2 residents (R2), observed during catheter cares. -The facility had no policy to direct staff for daily suprapubic catheter site care. -R2 had a urinary tract infection (UTI) with sepsis in September 2024. -Registered Nurse (RN) G did not perform hand hygiene or glove change during suprapubic catheter care. Findings: Facility had no policy for staff to follow and direct the care for a suprapubic catheter site care. According to MediLexicon International. (n.d.). What to know about e.coli uti treatment. Medical News Today.https://www.medicalnewstoday.com/articles/e-coli-uti-treatment, If bacteria get into the bladder and travels to the bladder, they can cause an infection. CAUTIs can become serious, especially in those with weakened immune systems and other health conditions. Risk of infection can be significantly reduced by washing hands…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not assess trauma and care plan person centered approaches to prevent re-traumatization for 1 out of 1 resident reviewed for trauma informed care (R30). R30's diagnosis includes post-traumatic stress disorder (PTSD) and past trauma of her sister dying. The facility did not assess R30's trauma and care plan individual person-centered approaches to prevent potential re-traumatization. Findings Include: The facility policy titled Trauma Informed Care not dated, states the following: Policy: It is the policy of this facility to provide care and services, which in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/re re-traumatization. Policy Explanation and Compliance Guidelines: 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility did not ensure expired medications were removed from currently used supply in the medication storage room refrigerator. This occurred for 1 of 1 medication storage rooms observed. An opened bottle of a resident's (R) multiuse medication kept in the medication storage room refrigerator was labeled with a beyond use date of 6/7/25. This medication was expired and had been given to resident (R34) since it expired, resulting in the potential to affect 1 out of 49 residents that reside in the facility (R34). Findings include: The facility's policy titled, Storage of Medication Requiring Refrigeration not dated with an implemented or reviewed date, but provided by facility upon request of policy, states in part, .5. Staff should observe proper storage and labeling requirements for all medications and vaccines during the performance of their daily tasks and should demonstrate safety in regard to the medication's integrity, such duties should include but not be limited to: . c. Remove any expired medications from active stock…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 for 1 of 2 residents (R2), observed during catheter cares. Registered Nurse (RN) G did not perform hand hygiene or glove change during suprapubic catheter care. Findings: Facility had no policy for staff to follow and direct the care for a suprapubic catheter site care. Facility policy titled Hand Hygiene with no date implemented or date revised stated in part: .2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .after handling contaminated objects .before performing invasive procedures .before and after handling clean or soiled dressings .after handling items potentially contaminated with blood, body fluids, secretions, or excretions .…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-26 · tag F0623 — isolated
    Provide 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 record review, interview, and policy review, the facility failed to ensure written notice of transfer was provided for three residents (R) (R2, R7, and R8) of three residents reviewed for hospitalizations. These failures had the potential to contribute to confusion at discharge or a lack of understanding of appeal rights. Findings include: Review of the policy titled, Transfer and Discharge (including AMA [against medical advice]), dated August 2020, revealed, The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge b. The effective date of transfer or discharge c. The specific location . to which the resident is to be transferred or discharged d. An explanation of the right to appeal the transfer or discharge to the State e. The name, address (mailing and email) 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-14 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop and initiate a comprehensive care plan with targeted interventions for a resident to identify and manage behavioral tendencies. This occurred for 1 of 5 residents (R) reviewed for care planning (R4). Facility did not develop and implement a behavioral care plan with intervention identified for handling potential inappropriate sexual behaviors for R4. Findings include: R4 was admitted to the facility on [DATE] with diagnoses including in part, paraplegia unspecified, type 2 diabetes mellitus, and muscle weakness. R4 was admitted with knowledge of being registered on sex offender list for minor issues. R4's Minimum Data Set (MDS) assessment, dated 09/08/24 identified R4 had a Brief Interview for Mental Status (BIMS) score of 15. This indicated R4 has intact cognition. The MDS assessment also identified R4 required substantial to maximal assistance of two people for transfers, chair to bed, and toileting. R4 required moderate assistance of one…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-05-02 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. Staff were observed not wearing covering over facial hair while preparing and serving food in the kitchen. This had the potential to affect all 46 residents in the facility. Findings include: According to the FDA Food Code 2022 documents at 2-402.11 Hair restraints: Effectiveness. (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens and unwrapped single service and single use articles. Facility policy and procedure entitled Maintaining a Sanitary Tray Line: States, in part, .During tray assembly, staff shall: .Wear hair restraints (bonnets, caps, nets, to cover hair) when preparing or handling food . On 05/01/24 at 7:25 AM, Surveyor observed Dietary Manager (DM)…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility did not ensure that 2 of 4 sampled residents (R) who are unable to carry out activities of daily living received the necessary services of toileting and incontinence care to maintain good personal hygiene. (R16 and R29) Findings include: R16 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, muscle weakness, atrial fibrillation, and transient ischemic attack. R16's minimum data set (MDS) assessment, completed on 04/08/24, confirmed R16 scored 09 during a brief interview for mental status (BIMS), indicating severely impaired cognition. R16 is incontinent of urine and frequently incontinent of bowel movements. R16 requires substantial maximal assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R16's care plan was initiated on 08/03/20, and included the following interventions: PERSONAL HYGIENE care plan: -The resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not ensure each resident receives necessary respiratory care and services that is in accordance with professional standards of practice for 1 of 1 resident (R) reviewed for respiratory care. (R9) The facility has no system in place to replace R9's continuous positive airway pressure (CPAP) equipment according to manufacturer's recommendations. This is evidenced by: The facility policy, entitled CPAP/BiPAP Cleaning, dated 2023, states: Follow manufacturer instructions for the frequency of cleaning/replacing filters and servicing the machine. The user guide for ResMed AirSense10 states: Caring for you device Check the air filter and replace it at least every 6 months. Design Life air tubing: 6 months R9 utilizes a CPAP mask ResMed Quaatro. The manufacturer's website resmed.com recommends replacement of the mask cushion every month, replacement of the mask frame system every 3 months, and replacement of the headgear every 6 months. R9 was admitted to the facility in 2017 and has diagnoses that include obstructive sleep apnea,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not maintain an infection control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Staff did not do hand hygiene between glove changes during wound care observation for 1 of 2 residents (R). (R39) Residents were not provided hand hygiene prior to meals in the dining room and resident rooms. This affected 17 residents in the dining room (R23, R37, R8, R152, R18, R45, R1, R25, R26, R9, R17, R47, R20, R19, R7, R21, R6) and 4 residents in their rooms (R3, R5, R28, and R13) Findings include: Example 1 Facility policy entitled Hand Hygiene, last reviewed 04/2023, stated in part, .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . R39 was admitted to the facility on [DATE] with diagnoses including, in part, cerebrovascular accident (CVA)…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-26 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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

    Based on interview and record review, the facility did not ensure each residents' drug regimen is free from unnecessary drugs in 1 (R11) of 4 residents reviewed. An unnecessary drug is any drug when used in the presence of adverse consequences, which indicate the dose should be reduced or discontinued, or without adequate indications for use. R11 was prescribed an antibiotic (Keflex) for a UTI (urinary tract infection) 3x week without having localizing symptoms of a UTI or adequate diagnosis. The facility had no evidence that R11 met criteria for continued use of the prophylactic antibiotic or signs and symptoms exhibited by R11 since last recertification survey of 2/10/2022. This is evidenced by: 04/25/23 Reviewed facility policy Infection Surveillance and Infection Prevention and Control Program implemented on 8/22 and reviewed and revised 4/23, stating, in part: that the facility uses the McGeer's criteria document for UTI without an indwelling catheter includes in part: Resident who does not have an indwelling urinary catheter and has at least three of the following signs 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2024-05-02 · tag F0623 — widespread
    Provide 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 interview and record review, the facility did not provide written notification of transfer to the Office of State Long-Term Care Ombudsman for 2 of 2 residents (R5 and R46) reviewed for transfers. The facility failed to have a system in place to ensure notifying the State Long-Term Care Ombudsman of hospital transfers. This had the potential to affect all 46 residents that reside in the facility. Findings include: On 05/01/24, Surveyor requested Ombudsman notification for R5's hospitalization in 09/2023. On 05/01/24 at 12:23 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated the facility had not been providing the notification to the Ombudsman. DON B reported staff were unaware of this requirement. On 05/01/24 at 2:12 PM, Surveyor interviewed Social Services Director (SSD) G. SSD G confirmed the facility had not been providing notification to the Ombudsman as staff were not aware of this requirement. SSD G stated the facility was developing a plan to correct this. Example 2: R46…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
OPPENHEIMER, AARONIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 01/06/2021
RAMI, ISAACIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 01/06/2021
STEINMETZ, TIMOTHYIndividualCONTRACTED MANAGING EMPLOYEEsince 01/01/2024
MCARDLE, MELISSAIndividualW-2 MANAGING EMPLOYEEsince 01/06/2021

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.

$6.9M
Net patient revenuemost recent cost report
+15.2%
Operating marginrevenue minus expenses
$1.3M
Related-party expense22% of expenses
Who pays — share of resident-days
Medicaid 44%Medicare 22%Other / private 33%

This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 22% 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

$337per resident / day
operating cost
$10,251per month
≈ monthly operating cost
$398per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WI

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.

Typical monthly cost in Wisconsin
$10,646/mo
Nursing home (semi-private)
$12,319/mo
Nursing home (private)
$6,540/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525513. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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