Soldiers Grove Health Services
101 Sunshine Blvd., Soldiers Grove, WI 54655 · For profit - Corporation · 50 certified beds · (608) 624-5244 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (9% vs 45% nationally) — better care continuity
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- 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-based staffing score sits well above its independent inspection score
- its independent health-inspection 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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 | 24.1% | 16.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.9% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.5% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.5% | 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 | 5.7% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.2% | 18.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 27.2% | 16.9% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.5% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 5.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.9% | 24.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.1% | 15.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 87.5% | 82.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.5% | 23.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.8% | 15.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.24 | 1.66 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.87 | 2.29 | 1.80 | typical |
‡ 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.
44.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 44.0%CMS range 30.5–56.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 5.9–15.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 86.7% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.42 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 50 beds and averages 36.5 residents a day — about 73% occupied, or roughly 14 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.04 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 3.21 hrs/resident/day on weekends vs 3.83 on weekdays — 16% thinner on weekends. RN hours go from 1.19 to 0.68 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 9% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · Gcited before2025-07-21 · 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 interview and record review, the facility did not ensure each resident receives the necessary care and services in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 13 sampled residents (R20) resulting in actual harm. R20 was self-transferring multiple times and on the eighth attempt, suffered an unwitnessed fall. The facility failed to provide an assessment completed by an RN (Registered Nurse) or with RN oversight at the time of the fall. The facility failed to notify the physician timely of the fall, failed to relay all of R20's symptoms to physician and DON B (Director of Nursing) at the time of the fall, and failed to notify physician of changes of condition following the fall. R20 was found to have a left acetabular (hip joint socket) fracture. Evidenced by:Facility policy, titled Change in Condition of the Resident, reviewed 9/20/22, includes, in part: .When a resident presents with a possible change in condition, after a fall or other possible trauma,…
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.
- Actual harm · Gcited before2025-07-21 · 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 interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 residents (R20) reviewed for falls resulting in actual harm.R20 was self-transferring multiple times and on the eighth attempt, suffered an unwitnessed fall. The facility failed to provide temporary interventions to address the self-transferring. R20 was found to have a left acetabular (hip joint socket) fracture.This is evidenced by:Facility policy, titled Fall Prevention and Management Guidelines, reviewed and revised on 7/18/24, states in part; Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not because of an overwhelming external force. The event may be witnessed,…
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 before2025-07-21 · 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
Number of residents sampled:34Number of residents cited:34Based on record review and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 34 residents who reside in the facility.The facility's dishwasher was not reaching appropriate temperatures.Findings includeThe facility employs a high temperature dishwasher to clean and sanitize its dishware.The facility's policy, titled Warewashing, states, in part, All dishware, service ware, and utensils will be cleaned and sanitized after each use.the dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware.all dish machine water temperatures will be maintained in accordance with manufacture recommendations for high temperature or low temperature machines.temperature and/or sanitizer concentration logs will be completed, as appropriate.The facility's dish machine log indicates on the bottom of the form that the wash temperature…
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 · F2025-07-21 · 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
Number of residents sampled:34Number of residents cited:34Based on interview and record review, the facility has not established 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 has the potential to affect the census of 34 residents. The facility has not established a line list that reflects resident's symptoms, lab results, symptom onset date, and the type of infection a resident has. Evidenced by: The facility's policy titled Infection Surveillance dated 3/8/23 states in part .1. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required. The facility's policy titled Infection Prevention and Control Program dated 7/23/24 states in part .3. Surveillance: a. A system 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 · D2025-07-21 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 1 resident reviewed for grievances (R13). R13 expressed concerns regarding asking for assistance with ADLs (Activities of Daily Living) that was not completely investigated by the facility. Evidenced by: The facility's policy titled Grievance Policy dated 7/2022 states in part .When a Complaint/ Grievance Report is initiated: .The original form will then be forwarded to the department head for which the Grievance pertains to (i.e. Dietary Manager for food and dining related issues, DON (Director of Nursing) for any nursing or clinical related issues.). The Department Head that is assigned the concern form is responsible for investigating the issue within 72 hours of being assigned the grievance. The Grievance Officer will ensure: during the investigation, the Grievance Officer will prevent any potential or further violation of resident rights.The Grievance…
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 · D2025-07-21 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled:1Number of residents cited:1Based on interview and record review, the facility did not follow through with the appropriate steps of the Preadmission Screening and Resident Review (PASRR) process for 1 of 1 resident (R8) reviewed.The facility does not provide R8 with specialized services per PASAAR Level 2 recommendations.Evidenced by:Per the facility, they do not have a PASRR Policy and Procedure.According to Wisconsin Department of Health Services at https://www.dhs.wisconsin.gov>pasrr, states, in part: . Preadmission Screening and Resident Review (PASRR) is a federal requirement established to identify individuals with mental illness and/or intellectual developmental disability to ensure appropriate placement in the community or a nursing facility.In brief, PASRR requires all applicants to Medicaid-certified nursing facilities be assessed to determine whether they might have an intellectual disability or mental illness. This is called a Level I screen. The purpose of a Level 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.
- Potential for harm · D2025-07-21 · 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 Number of residents sampled: 12Number of residents cited:1Based on interview and record review the facility did not develop a comprehensive care plan or review and revise the comprehensive care plan for 1 of 12 sampled residents (R13).R13's care plan did not address the type of assistance required for dressing.Evidenced by:The facility's policy titled Comprehensive Care Plan revised on 9/23/22 states in part .1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well- being.R13 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (left sided weakness/ paralysis following 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.
- Potential for harm · D2025-07-21 · 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 Number of residents sampled:2Number of residents cited:1Based on interview and record review the facility failed to maintain acceptable parameters of nutritional status and consult with the residents Physician on this for 1 of 2 residents (R4) reviewed for nutrition of a total sample of 13 residents. R4 had a severe weight loss of 11.29% in 6 months. The facility did not put interventions into place to prevent weight loss or update the physician during the 6-month period. Evidenced by:The facility policy entitled Weight Monitoring, dated 12/21/22, states, in part: . Policy: The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents.Procedure:Weight Assessment.7. The dietician will review the monthly weights to follow individual weight trends over time. Weight trends will be evaluated by the interdisciplinary team whether or not the criteria for significant weight change have been met.8. The threshold for significant weight change will be based on 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 · D2025-07-21 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled:7Number of residents cited:3Based on interview and record review, the facility does not follow a nationally recognized standard of practice for infection control or monitoring antibiotic use, and they do not have protocols in place to obtain cultures and other reports to ensure residents are receiving the correct antibiotic for 2 of 7 residents (R30 and R25) reviewed for infections. R30 was started on an antibiotic and had no documented signs of an infection. R25 received orders for a UA (Urinalysis) without meeting criteria and was subsequently placed on an antibiotic. Evidenced by: The facility's policy titled Antibiotic Stewardship Program revised on 11/18/22 states in part .4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: i. Nursing staff shall assess/ gather data on residents who are suspected to have an infection and notify the physician. Documentation shall include the assessment or data gathered and 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 · D2024-09-04 · 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 interview and record review, the facility did not immediately consult with the resident's physician when there is a need to alter treatment for 1 out of 3 residents (R) reviewed for physician notification (R1). R1 had a change of condition and the facility failed to update the physician. R1 had an oxygen saturation level outside of parameters on several occasions and the physician was not updated. Facility staff also increased R1's oxygen without updating the physician or receiving orders to increase oxygen. This is evidenced by: Facility policy, titled, Change in Condition of the Resident, last reviewed 9/20/22, states in part . Policy: A facility should immediately inform the resident; consult with the resident's physician; and notify consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-04 · 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 observation, record review, and resident and staff interviews, the facility did not develop and implement a comprehensive resident-centered care plan for 1 of 5 sampled residents reviewed (R2). R2 has a history of making false allegations. This is not on R2's comprehensive care plan. Evidenced by: The facility's Comprehensive Care Plan policy, dated 9/23/22, includes, in part, the following: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. g. Individualized interventions for trauma survivors that recognizes the interrelation…
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 before2024-05-09 · 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 and interview, the facility failed to distribute food under sanitary conditions, did not utilize proper glove use and handled food without proper hand hygiene. This has the potential to affect all 35 residents who reside in the facility. This is evidenced by: The facility policy and procedures for Healthcare Services Group entitled, Infection control overview & Policy, states in part, Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination. The policy also states food should be labeled and dated with a prepared date and a use by date. On 05/06/24 at 9:30 AM, during the initial kitchen tour, Surveyor toured with Certified Dietary Manager (CDM) C and observed opened and undated containers of a gallon of chocolate milk, gallon of whole milk, jug of buttermilk ranch dressing, and bag of frozen cheese omelets. On 05/06/24 at 9:30 AM, Surveyor observed the sign on kitchen bulletin board stating in part .milk labeling 4/21/26: Document on Jug/Carton the date…
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 12 citations
- Potential for harm · F2024-05-09 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility did not ensure the mandatory staffing data that had been submitted from 07/01/23-12/31/23 (Quarter 4 2023 and Quarter 1 2024) was complete, accurate, and auditable. This can affect all 35 residents residing in the facility. This is evidenced by: The Payroll Based Journal (PBJ) Staffing Data Reports that were generated quarterly document that the facility triggered for Excessively Low Weekend Staffing and One Star Staffing Rating from 07/01/23-12/31/23 (Quarter 4 2023 and Quarter 1 2024). There were no specific dates listed. Surveyor reviewed the facility's time sheets for weekends in the months in question and found adequate staffing on all weekends. Surveyor reviewed the facility's Daily Schedule sheets for the months of October 2023 to December 2023 and did not find any weekends that had low weekend staffing concerns. Surveyor interviewed family members and residents who did not share any complaints or concerns regarding weekend staffing. On 05/07/24 at 1:04 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and [NAME]…
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 before2024-05-09 · 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
Based on record review and interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (R21). Findings include: The facility policy entitled, Fall Prevention and Management Guidelines, last reviewed/revised on 11/09/22, lists in part . -provide interventions that address unique risk factors. -interventions will be monitored for effectiveness. -contributing factors to fall -review of investigation and determination of potential root cause of fall. The facility policy entitled, Resident Alarms, last reviewed/revised on 09/09/22, states in part, The facility shall establish and utilize a systematic approach for the safe and appropriate use of resident alarms which includes verifying alarms are working properly. R21 was admitted to facility on 08/27/21 and has diagnoses that include, Alzheimer's disease, unspecified dementia, difficult in walking and muscle weakness. R21's most recent Minimum Data Set (MDS) Assessment, which was a significant change in condition, dated 02/12/24, and indicates…
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 · D2024-05-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 assessments for bowel continence and interventions to maintain current bowel continence were implemented to maintain bowel function for 1 of 1 resident reviewed with a bowel incontinence (R25). This is evidenced by: R25 was admitted to the facility on [DATE] and has diagnoses that include neurogenic bladder, acute pyelonephritis, diabetes mellitus type 2 and mild intellectual disability. R25's Minimum Data Set (MDS), dated [DATE], indicates that R25 has a Brief Interview for Mental Status (BIMS) score of 99 (unable to complete interview), an indwelling Foley catheter, bowel continence of not rated, uses a Hoyer lift for transfers and is dependent on staff for bowel continence. R25's MDS, dated [DATE], indicates that R25 has bowel continence rated at 02: frequently incontinent. R25's MDS, dated [DATE], indicates that R25 has bowel continence of 02: frequently incontinent. R25's care plan, dated 9/14/2022, states, Bowel incontinence…
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 before2024-04-02 · 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
Based on interview and record review, the facility did not ensure a care plan was developed for nicotine use for 1 of 2 residents (R) 1 reviewed for comprehensive care plans. This is evidenced by: The facility policy, entitled Comprehensive Care Plan dated 09/23/22, states in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment .2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment . Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed. On 03/19/24 at 8:30 AM, Surveyor conducted a record review of progress notes for Resident (R) 1. A note stating: 1/25/2024 03:41 .Behavior Note .Staff called to resident room tonight, found to be incontinent of stool .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 · Dcited before2024-04-02 · 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
Based on interviews and record reviews, the facility did not ensure that the resident environment remained as free of accident hazards as possible. The facility did not assess the resident's ability to use e-cigarettes after determining that the resident used nicotine products. This occurred for 1 of 2 residents (R) 1 reviewed for assessments related to nicotine use. This is evidenced by: The facility policy, entitled Smoking Policy dated 07/14/22, states in part: This center shall establish and maintain a safe resident environment, while maintaining resident rights, smoking or nicotine use will be limited to designated areas, supervision and safety plans . 1. Residents who smoke or use smokeless tobacco products shall have a Nicotine Assessment completed upon admission, quarterly, annual and PRN. Residents or responsible party must be in agreement to nicotine use . Unsafe practices will result in IDT review of Nicotine Assessment and care plan interventions. On 03/19/24 at 8:30 AM, Surveyor conducted record review of progress notes for Resident (R) 1. A note stating: 1/25/2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-26 · 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 observation, interview, and record review, the facility did not ensure Residents (R2 and R3) with pressure injuries/ulcers receives necessary treatment and services consistent with professional standards of practice to prevent infection for 2 of 3 residents reviewed for pressure injuries. LPN C (Licensed Practical Nurse) did not perform appropriate hand hygiene while providing wound care to R2. LPN D did not perform appropriate hand hygiene while providing wound care to R3. This is evidenced by: Facility policy 'Clean Dressing Change,' states in part: Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines: 5. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: d. Use no-touch techniques to remove ointments and creams from their containers (i.e. use…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-10 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 interview and record review, the facility did not ensure that alleged violations involving abuse are reported immediately for 1 of 3 Residents (R2) reviewed for abuse. The facility filed a self-report on 6/17/23 regarding a staff member pushing R2 into a bedside table. The Housekeeper E did not immediately report the incident to their direct supervisor. Education was not provided to staff regarding abuse after the incident occurred. Evidenced by: The facility's policy and procedure entitled Abuse, Neglect and Exploitation dated 7/15/22, states, in part: Policy: It is the policy of this facility provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . III. Prevention of Abuse, Neglect and Exploitation . B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation 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 · D2023-08-10 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 2 of 3 residents (R2 and R3). The facility did not interview all staff involved regarding an allegation of abuse for R2 and R3. The facility timeline of events does not match written statements from staff or Surveyor interviews. The facility failed to educate all staff after the investigation was concluded. Evidenced by: The facility policy titled, Abuse, Neglect and Exploitation, with a revised date, 7/15/2022, states, in part; .V. Investigation of Alleged Abuse, Neglect and Exploitation B. Written procedures for investigations include: 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s); 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-10 · 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
Based on interview and record review, the facility did not ensure that each resident had an accurate and thorough assessment post fall. R1 did not have vital signs (temperature, pulse, respirations, blood pressure) completed with each neurological assessment post fall on 8/1/23. This is evidenced by: The facilities Policy and Procedure entitled Fall Prevention and Management Guidelines dated 11/8/22, documents, in part: .7. When any resident experiences a fall, the facility will: a. Complete a post-fall assessment and review .2) Neuro checks for any unwitnessed fall or witnessed fall where resident hit their head: - Initially then q (every) 15 minutes x 3, - Q 30 minutes x 2, - Hourly x 4, - Q 8 hours x 9, - Or as indicated by the physician . [SIC] A neuro check or neurological assessment includes the following: vital signs, orientation (person, place, time, situation), LOC (level of consciousness), pupils (size, reaction to light), responses, pain, and extremities (movement, sensation). The purpose of completing each of these areas at different time intervals is to be able to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-13 · 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 interview and record review the facility failed to ensure that residents' receive treatment and care in accordance with professional standards of practice, for 1 of 17 sampled residents (R42). R42's Nurse Notes reflect a change in his condition. Facility staff failed to assess R42 during a change of condition, failed to update R42's Medical Doctor, and failed to update R42's Responsible Party. Evidenced by: Facility policy entitled Change in Condition of Resident, reviewed 9/20/22, includes, in part: When a resident presents with a possible change in condition, after a fall or other possible trauma, or noted changes in mental or physical functioning: assess the resident's need for immediate care/medical attention. Provide emergency care as needed. Assessment/evaluation could include, but is not limited to, the following: vital signs, oxygen saturation, blood glucose level .pain- location, type, intensity, duration, causative factors . alteration in level of consciousness, ability to respond . bowel 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 · D2023-04-13 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure adequate monitoring for medications with a black-box warning for 1 of 5 Residents reviewed for unnecessary medications out of a total sample of 17 Residents (R35). R35 receives Depakote, Keppra, and Trileptal for seizure activities. All 3 of these medications have black-box warnings. R35 was not being monitored for side effects or for effectiveness of these medications by a licensed nurse. Black box warnings, are required by the U.S. Food and Drug Administration for certain medications that carry serious safety risks. Often these warnings communicate potential rare but dangerous side effects, or they may be used to communicate important instructions for safe use of certain drugs. This is evidenced by: Facility policy entitled 'Medication Monitoring Medication Management,' dated 01/23, states in part: . Medication Management, Policy each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-13 · 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 Example 2: The facility's policy titled Psychotropic Medication states the following: *A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Syntrophic drugs include but are not limited to the following categories: anti psychotics, antidepressants, anti anxiety, and hypnotics. * The indications for initiating, withdrawing, or withholding medications, as well as the use of non pharmacological approaches, will be determined by assessing the residents underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment. * The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication liberation residents, their families and/or representatives about professionals, interdisciplinary team. * Indications psychotropic drug will be documented in the medical record. Permission screen appropriate mission data shall be utilized for determining indications for use order upon…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to NORTH SHORE HEALTHCARE — 59 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.7 | -0.7 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 4 of 5 | 3.4 | +0.6 vs chain |
| Quality measures | 3 of 5 | 2.5 | +0.5 vs chain |
The other 58 homes this chain runs (chain average 2.7★, per CMS)
Showing 40 of 58; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| NICOLET NATIONAL BANK | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2018 |
| CIBC BANK USA | Organization | 5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 12/31/2024 |
| BAUMANN, TROY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/19/2017 |
| HOEHN, JEFFREY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/19/2017 |
| CLIFTONLARSONALLEN LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/22/2018 |
| CONTINUUM THERAPY PARTNERS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2025 |
| NORTH SHORE HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2018 |
| NSH REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2025 |
| WIPFLI LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2025 |
| BELONGIA, CHRISTINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2019 |
| ENGEL, KAYLEE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/31/2026 |
| GEE, DARREN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/30/2021 |
| GREER, LAUREN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/29/2023 |
| PATZER, COLLEEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/14/2023 |
| PURTELL, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2018 |
| WOODY, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/22/2024 |
| 101 SUNSHINE BLVD LLC | Organization | ADP OF THE SNF | since 01/31/2018 |
CMS files one row per role, so the 36 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
8 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 $224K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WI
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 525622. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-21, 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.