Sun Prairie Senior Living
228 W. Main St., Sun Prairie, WI 53590 · For profit - Corporation · 52 certified beds · (608) 837-5959 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- 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 1 actual-harm citation
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (58%) runs well above the national median (45%)
- CMS ownership filings flag it as owned by a private-equity firm or REIT — a category that performs worse on staffing on average, though that average says nothing certain about this home, and CMS filings undercount these ties, so other homes here may have them unflagged (what the research actually shows →)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 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 4 to 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.
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 | 5.6% | 16.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.6% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 2.7% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.8% | 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 | 6.4% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 19.1% | 18.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 3.4% | 16.9% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.4% | 5.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 31.4% | 24.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.9% | 15.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.0% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 89.7% | 82.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.0% | 23.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.3% | 15.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.23 | 1.66 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.46 | 2.29 | 1.80 | better |
‡ 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.
53.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 58 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 84 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.35 therapist hours per resident per day in 2026Q1 — more than 60% 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 | 53.7%CMS range 42.8–64.7 | 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 | 10.6%CMS range 7.0–16.3 | 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 | 65.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 54.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 53.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 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 | 0.9% | 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 | 5.8%CMS range 2.9–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 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 52 beds and averages 34.7 residents a day — about 67% occupied, or roughly 17 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 3.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.51 hrs/resident/day on weekends vs 3.78 on weekdays — 7% thinner on weekends. RN hours go from 0.80 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · G2023-11-30 · 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 that 1 (R19) of 12 residents out of a total sample of 14 residents received assessment and appropriate and timely medical care with a change in medical condition. R19 had an unwitnessed fall on 10/21/23 at 6:15 PM. R19 experienced change of condition and the facility failed to properly assess range of motion (ROM)/change in ambulation ability on 10/21/23. The facility failed to identify change in resident when resident experienced the inability to move right leg and increased weakness on 10/21/23 and the morning of 10/22/23. R19 went to emergency room on [DATE] at 11:00 AM and was diagnosed with a right hip fracture. Evidenced by The facility policy titled, Notification of Change in Condition, with a revision date of 12/31/22, states, in part; .PURPOSE to ensure appropriate individuals are notified of change in condition. The facility must inform the resident, consult with the resident's physician and if known notify the resident's legal…
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 before2026-04-01 · 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, interview, and record review, 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.Surveyor observed cereal spilled on the floor and an open container for storing dry pasta in the kitchen pantry.Surveyor observed milk temperatures to be out of range on room trays being delivered to residents for lunch.Surveyor observed sanitizing solution to test outside of the recommended range for parts per million (ppm) concentration.Surveyor observed male staff to have facial hair and to be working with resident food without hair restraints in place.Surveyor observed a refrigerator for resident snacks to be broken with melted, warm food inside of the refrigerator and freezer. This is evidenced by: Example - Pantry foodSurveyor requested a food safety policy, but the facility was unable to provide one.The Food and Drug Administration (FDA) Food Code 2022, includes in part: Food Storage . Food shall be protected from contamination by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-01 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 2 of 16 sampled residents (R4 & R44). R4 reported to Surveyor that their divider curtain was soiled and that their carpet had not been vacuumed. R44 reported that their toilet overflows and no one will fix it. Evidenced by: Facility did not provide a policy on housekeeping. Example 1: R4 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease, congestive heart failure, and type 2 diabetes mellitus. R4's most recent Minimum Data Set (MDS) dated [DATE] states that R4 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R4 is cognitively intact. On 3/29/26 at 9:29 AM, Surveyor interviewed R4. R4 reported to Surveyor that their room divider curtain was soiled, and it grosses out their visitors.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · 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 2 residents reviewed for grievances (R26). R26's Activated Power of Attorney (APOA) expressed concerns regarding R26 not getting out of bed for activities and that R26 had a broken wheelchair. The facility failed to provide a written resolution to R26's APOA. Evidenced by:The facility policy titled Resident Concern Process last reviewed 12/16/24 states in part .4. The facility staff will follow these basic steps in response to a complaint: *Listen to the concern without interruption *Thank the person who brought the concern to staff * Apologize to the person bringing the concern and acknowledge that what happened is not our standard * Not make excuses for why or how this has happened * Take steps to correct the problem *Make the problem their own by following up to make sure it is resolved and stays resolved *Any concern that is suspected to be abuse,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · 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 all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 16 Residents (R43) reviewed for abuse.R43 and FM G (Family Member) reported an allegation of abuse and the facility did not submit a report to the State Agency (SA).Evidenced by:The facility's Abuse and Neglect Procedural Guidelines policy, dated 8/29/19, states, in part: Facility has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. 1. The facility has implemented processes in an effort to provide a comfortable and safe environment. 2. The Executive Director and Director of Health Services are responsible for the implementation and ongoing monitoring of abuse standards and procedures.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · 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 ensure it had evidence that an alleged violation was thoroughly investigated for 2 of 16 Residents (R27 and R34) reviewed for abuse. Facility did not thoroughly investigate an allegation of abuse (resident-to-resident) for R27 and R34. Evidenced by: Facility Policy entitled 'Abuse, Neglect and Exploitation Procedural Guidelines, states in part: .The facility has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. Procedures: The facility has implemented processes in an effort to provide a comfortable and safe environment. The Executive Director (also known as NHA A, Nursing Home Administrator) and Director of Health Services are responsible for the implementation and ongoing monitoring of abuse standards and procedures. Physical Abuse - includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Resident to resident abuse with or without cause.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 the assessments must accurately reflect the resident's status for 1 of 16 residents' (R5) Minimum Data Sets (MDS) reviewed for accuracy. R5's MDS dated [DATE] does not have her pressure injury (PI; localized damage to skin and underlying tissue caused by prolonged pressure) coded correctly. This is evidenced by: The Facility does not have a Policy and Procedure for MDS accuracy. The Facility follows the Resident Assessment Instrument (RAI) manual. Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/23, documents the following, in part: .The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR (Code of Federal Regulations) 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status . On 7/16/25 Hospice identified, assessed and measured R5's PI's as follows: Pt (patient) now has a 9.0 x 17.3 cm (centimeter) open area that at the coccyx…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · 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 Based 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 5 residents (R43) reviewed for PASRR screening. R43 did not have a PASRR Level I (1) completed. This is evidenced by: The facility provided the Wisconsin Department of Health Services Forward Health Update, volume 2023-37, dated 11/2023, for their PASRR policy. The Forward Health Update states, in part: Federal regulations.require that all individuals seeking admission to a Medicaid-enrolled nursing facility be screened to determine the presence of a major mental illness and/or developmental disability. Nursing facilities fulfill this requirement by conducting a preadmission Level I screen for anyone who meets the definition of a 'new admission.'. R43 was admitted to the facility on [DATE], was on hospital leave from 2/21/26-3/20/26, and readmitted to the facility on [DATE], with diagnoses that include Parkinson's disease (neurological…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 2 of 5 sampled Residents (R4 & R41).R4 reported that they have only had 1 shower since their admission to the facility.R41 reported that they have only had 1 shower since their admission to the facility. R41 has facial hair that is approximately 1/4- 1/2 long and facility staff has not shaved R41.Evidenced by:The facility does not have a policy for ADLs (Activities of Daily Living).Example 1R4 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease, congestive heart failure, and type 2 diabetes mellitus.R4's most recent MDS (Minimum Data Set) dated 2/25/26 states that R4 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R4 is cognitively intact. R4's MDS also states that R4 requires…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that the resident environment remains as free of accident and hazards as possible for 2 of 4 sampled residents (R27 & R26). Surveyor observed R27's motorized wheelchair (Motorized Assistive Devices) being charged in the conference room. NHA A (Nursing Home Administrator) states the wheelchair should be charged in the Conference Room. Surveyor observed the Conference Room to not have a fire safe door. R26 has an order to be supervised at meals. The facility was not providing supervision with breakfast. Evidenced by The facility did not have a policy for charging electric wheelchair batteries. The facility also did not have a policy for Motorized Assistive Devices. On 3/31/26 at 8:30 AM, Surveyor observed R27's wheelchair battery charging in the conference room while Surveyors were in the conference room. On 3/31/26 at 8:37 AM, Surveyor asked NHA A (Nursing Home Administrator) to walk to conference room with Surveyor. Surveyor showed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure a resident who requires BiPAP respiratory support was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 resident (R4) reviewed with BiPAP.R4 was admitted to the facility with an order for BiPAP; the order was never transcribed and R4 has not received the BiPAP since admission.Evidenced by:The facility does not have a policy for respiratory care.R4 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease, congestive heart failure, OSA (Obstructive Sleep Apnea), and type 2 diabetes mellitus.R4's most recent MDS (Minimum Data Set) dated 2/25/26 states that R4 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R4 is cognitively intact.R4's hospital discharge orders dated 2/2/26 state in part .BiPAP/NPPV (Bilevel positive airway pressure/Non-invasive positive…
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 20 citations
- Potential for harm · D2026-04-01 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such 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 interview and record review the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 sampled resident (R4) reviewed for dialysis. R4 receives dialysis and the facility staff were not fluent in the emergency plan for a resident bleeding from their dialysis access site. This is evidenced by: The facility's policies titled Pre-Dialysis Patient Assessment and Post-Dialysis Assessment dated 12/1/2022 does not include an emergency plan. According to Clinical Journal of the American Society of Nephrology article titled Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies dated February 2017, .Vascular Access Hemorrhage: Hemorrhage from an AV access is an uncommon but potentially fatal complication if it is not recognized promptly and acted on with an appropriate intervention. Most fatal vascular access hemorrhages occur…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (R33) resident based on the review of medication storage in 2 of 3 medication carts.R33 was given oxycodone after the printed expiration date on the medication card.This is evidenced by:The facility's policy, titled General Guidelines for Administration of Medication, effective 12/1/22, states in part: Purpose: To maintain the safety and comfort of the patient regarding the administration of medication. Procedure:.20. Expiration dates for all medication in inventory are recorded and the inventory must be monitored on a monthly basis. This ensures that medication is replaced prior to the expiration date.R33 was admitted to the facility on [DATE] with diagnoses that include encephalopathy (group of conditions that cause brain dysfunction), pain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 and interview, the facility did not ensure that all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 2 residents (R5 and R33) based on the review of medication storage in 2 of 3 medication carts.R5's lorazepam tablets were expired.R33's oxycodone tablets were expired.This is evidenced by:The facility's policy, titled Medication Storage, revised on 11/1/22, states in part: .6. SOP (Standard Operating Procedure) Details. E. Inspection of Storage Areas i. The pharmacy must inspect every medication in the pharmacy on a monthly basis for expiration dating, package integrity and storage area cleanliness. ii. Outdated or otherwise unusable medications must be immediately pulled from active inventory and segregated to an area to prevent unintentional use.Example 1On 3/30/26 at 4:00 PM, Surveyor observed the medication cart for rooms 18-46 with RN L (Registered Nurse). Surveyor noted that R5's lorazepam (0.5 mg tablets) had an expiration date of 1/17/26. There were 14 lorazepam tablets remaining in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 infection for 1 of 1 Resident (R24) observed for wound care and 1 of 1 Resident (R35) on transmission based precautions. IP/WN C (Infection Preventionist / Wound Nurse) had breaches in infection control when IP/WN C did not perform hand hygiene after cleansing R24's wound prior to touching clean dressings. R35's is on contact precautions; staff removed a used cup from R35's room. Evidenced by: The facility's Guideline for Handwashing/Hand Hygiene policy, dated 11/18/25, states, in part: The purpose of this policy is to: Handwashing is the single most important factor in preventing transmission of infections. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known 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.
- Potential for harm · D2025-06-06 · 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 interview, and record review, the facility failed to develop a person-centered comprehensive care plan to meet personal preferences and goals, or address the resident's medical, physical, mental, and psychosocial needs for 1 of 3 residents (R1). R1's comprehensive care plan does not include approaches for staff to follow for R1's care This is evidenced by: The facility's policy titled Comprehensive Care Plan Guideline, dated 5/22/18, includes the following: Purpose To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. Care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident. A comprehensive care plan will be developed within 7 days of completion with the admission comprehensive assessment. Problem areas should identify the relative concerns. Goals should be measurable and attainable.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-03 · 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 the resident environment remained as free of accident hazards as possible for 2 of 6 residents (R6 and R5) reviewed. CNA C reported performing solo transfers for residents requiring assist of two staff members. Evidenced by The facility's Resident Transfers policy, dated 12/16/24, states, in part: Overview To ensure the safety of residents and staff when performing mobility/transfer tasks.3. Campuses determine the amount of assistance required for transfers and record this on the Nursing admission Observation, the Care Assist profile, and the Resident Care Plan to provide communication to all staff regarding safe transfers. The facility's Guidelines for Resident Utilizing a Lift policy, dated 12/17/24, states, in part: Purpose To ensure the safety of residents and staff when performing lift transfer tasks.3.Staff should seek the assistance of a second person for those residents' care planned for assistance of two with the lifting device or 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.
- Potential for harm · F2025-01-09 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility did not ensure a Registered Nurse (RN) worked for 8 consecutive hours in a day, 7 days a week. This has the potential to affect all 33 residents (R) residing within the facility. On Wednesday, January 1, 2025, the facility did not have an RN in the building 8 consecutive hours on any of the three shifts. Evidenced by: On 1/8/25 at 9:43 AM, Surveyor reviewed nursing staff schedules and postings from 12/23/24 to 1/6/25. Surveyor observed no RN on the schedule for 1/1/25 and the posting which shows hours worked for nursing staff was filled with zeros for all three shifts under RN column for 1/1/25. On 1/9/25 at 2:40 PM, Surveyor interviewed DON B (Director of Nursing) regarding RN coverage. Surveyor asked DON B if he would expect an RN to be in the building every day for at least 8 consecutive hours; DON B stated yes. Surveyor asked DON B if he was in the building on 1/1/25; DON B indicated he was not in the building that day. Surveyor asked DON B why there wasn't an RN in the building on 1/1/25. DON B indicated there was supposed 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 · Fcited before2025-01-09 · 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, interview, and record review, 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 33 residents who reside in the facility. Surveyor observed male staff to have facial hair and to be working with resident food without hair restraints in place. The facility did not keep a record of when staff manually monitored the internal temperature of the facility's dishwasher. Surveyor observed food to be in circulation passed the use by date. Surveyor observed dented cans to be in circulation. Surveyor observed food that had been removed from the original packaging to be unlabeled and undated. Evidenced by Example 1 The Food and Drug Administration (FDA) Food Code 2022, includes in part: Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair; that are designed or worn to effectively keep their hair from contacting exposed food . On 1/7/25 at 11:10 AM, Surveyor observed Director of Food Services C 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 · Fcited before2025-01-09 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility 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 entire census of 33 residents. The facility was in a COVID-19 outbreak and the facility failed to do contact tracing and complete appropriate testing of residents and staff. The facility is not placing all staff that call in sick on the employee line list. The line list does not include last day worked, or area worked in. Staff was observed not wearing appropriate personal protective equipment (PPE) when administering eye drops to resident (R) R16. Surveyor observed staff providing care for a resident who was in enhanced barrier precautions without proper PPE. Surveyor observed staff administer eye drops to resident without donning gloves. Surveyor observed resident catheter to be in direct…
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 · D2025-01-09 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that every resident was treated with dignity and respect when providing activities of daily living (ADLs) for 1 of 12 residents (R13) reviewed for resident rights. R13 indicated to Surveyor that staff had transferred R13 to the dining room for breakfast in her pajamas after she informed them, she preferred not to go to the dining room in her pajamas. The facility did not ensure that R13 was treated with dignity and respect when transferring R13 to breakfast. Evidenced by: The facility's New admission Packet with Resident Rights, undated, states, in part: . Resident Rights: -Resident Rights. The resident has the right to a dignified existence, self-determination . inside and outside the facility . -Respect and dignity. The resident has a right to be treated with respect and dignity . -The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident . The facility's document entitled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 each resident had a safe, clean, comfortable environment or ensured housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 1 out of 33 residents (R18). R18 voiced concern her room does not get cleaned often. R18 pointed out to Surveyor her dresser being dusty, and floor does not get vacuumed. Surveyor observed dusty areas in R18's room. Surveyor observed tiny pieces paper/debris and lint particles on the carpeting. This is evidenced by: The facility's New admission Packet with Resident Rights, undated, states, in part: . Resident Rights: . -Safe environment. The resident has a right to a safe, clean, comfortable, and Homelike environment, including but not limited to receiving treatment and supports for daily living safely . R18 was admitted to the facility on hospice on 12/26/23 and has diagnoses that include metabolic encephalopathy (a brain dysfunction that occurs when there's an imbalance of chemicals in the blood, usually due to an underlying medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-09 · 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 interview and record review, the facility did not ensure that residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents (R382) reviewed for pressure injuries. R382 spent approximately 5 hours sitting in a wheelchair without a pressure relieving cushion. An air mattress was inflated and placed onto R382's bed without facility staff having knowledge of the manufacturer's recommendations for amount of air necessary for beneficial use. Evidenced by: Facility's Guidelines for Pressure Prevention policy, dated 12/17/24, states, in part: Purpose: To maintain good skin integrity and avoid development of pressure ulcers. Procedures: Care plan interventions shall be implemented based on risk factors identified in the nursing assessment. Interventions may include, but not be limited to: .Place on pressure reduction support surface (such as wheelchair…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure each resident (R) received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for falls (R16). R16 fell at the facility on 12/27/24 and staff failed to document details related to R16's fall, failed to update R16's medical doctor and failed to update R16's activated power of attorney failed to initiate neuro checks according to facility policy, and failed to record a Registered Nurse Assessment post fall. The facility did not identify root causes of R16's falls and did not implement individualized interventions. R16's fall intervention of a scoop mattress was delayed in arriving to the facility due to the holiday and the facility did not increase supervision or put anything different in place to prevent falls while they waited for the mattress to arrive and R16 fell three more times before the scoop mattress was in place. R16's family reported to the facility that R16 does not like to be in…
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 · D2025-01-09 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such 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 interview and record review, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 2 residents (R182) reviewed for pain. R182 was admitted to the facility with a right humerus fracture (a break in the upper arm bone). The facility failed to obtain R182's ordered narcotics and obtain a new order when R182 began refusing the acetaminophen, resulting in R182 having continued pain. Evidenced by: The facility policy titled Guidelines for Pain Observation and Management last reviewed on 12/17/24 states in part, .1. Observation of resident pain will be completed as part of the admission Observation and Data Collection form. a. Review other system observations for pain indicators. The pain indicators may include, but is not limited to an increase in behaviors, change in mood, withdrawal or a decrease in functional…
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 · D2025-01-09 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 3 errors in 25 opportunities that affected 3 out of 11 residents (R11, R14, & R5) included in the medication pass task, which resulted in an error rate of 16%. R11 received her Tylenol that was ordered for 7:00 AM at 8:42 AM resulting in a timing error. R14 received Vitamin B-12 and Vitamin D3 that was ordered for 7:00 AM at 8:51 AM resulting in a timing error. R5 received her short acting insulin and did not receive her meal within the required 15 minutes resulting in a medication error. Evidenced by: Facility policy entitled Medication Administration- General Guidelines, dated 11/18, states, in part: . Medications are administered as prescribed in accordance with good nursing Principles and practices and only by persons legally authorized to do so . Administration . 11) Medications are administered within 60 minutes of scheduled time, except before, with 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 before2025-01-09 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not offer each resident influenza immunizations, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza immunization for 1 of 5 residents (R16) reviewed for immunizations. R16 refused the influenza vaccine upon admission and was not offered the vaccine during the current flu season. Evidenced by: The facility's policy titled Guidelines for Influenza, Pneumococcal, & COVID-19 Immunizations last reviewed on 12/17/24 states in part, .4. Each resident/ responsible party will be provided annually with information regarding the risk and benefits of influenza vaccine and receive the immunization per their request, unless medically contraindicated. 5. From time- to- time specific strains of influenza develop that have a vaccine directed exclusively for that strain. [Facility Corporation] will provide this vaccine as it is available in accordance with the CDC…
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 before2023-11-30 · 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, interview, and record review, the facility did not ensure that the food was stored, distributed, and served in accordance with professional standards for food service safety. This has the potential to affect all 23 residents residing at the facility. Surveyor observed dirty hood vent and equipment, undated, unlabeled, and expired foods and beverages, and opportunity for cross contamination. The facility failed to ensure adequate dinnerware sanitization and document temperature of refrigerator and freezer. Findings include: The facility policy, entitled Refrigerator, dated 5/16/2017, states: Policy: Refrigerators. Purpose: to assure that appropriate temperatures are maintained in the campus refrigerators for the health and safety of our residents. Procedures: 1. Refrigeration .b. Will be monitored daily. c. Temperature checks will be documented on the refrigerator monitoring log daily . It is the responsibility of each department to maintain appropriate temperatures and logs. The facility policy, entitled Food Safety and Handling, dated 6/2/2016, states: Policy:…
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 · F2023-11-30 · 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 — the official record, unedited, may be distressing
Based on interview and record review, the facility did not ensure the mandatory submission of staffing data based on payroll data was completed. This has the ability to affect all 23 residents residing in the facility. Payroll Based Journal (PBJ) data was not submitted for the 3rd quarter of 2022. Findings include: PBJ staff data reports generated quarterly indicated the facility triggered for Failed to submit PBJ data for the fiscal year quarter 3 2022. On 11/30/23 at 4:08PM, NHA A (Nursing Home Administrator) and AVP S (Assistant [NAME] President) indicated this submission would have been the previous company. The facility is now under new ownership. NHA A and AVP S indicated they would talk to AVP's supervisor and provide more information if able. All current quarter's PBJ data has been submitted. No further information was provided to Surveyor.
- Potential for harm · D2023-11-30 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure residents with complications related to range of motion receives appropriate services and assistance to prevent further complications related to decrease in range of motion, for 1 of 12 resident's (R5) reviewed for ROM. The facility did not ensure R5's Physicians orders and care planed functional maintenance program was being followed. Finding include: R5 admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, unspecified. R5's Minimum Data Set (MDS) annual assessment, dated 10/15/23, states that R5 has a Brief Interview for Mental Status (BIMS) score of 99 indicating that R5's cognition is severely impaired. Section B of R5's MDS indicates that R5 is usually understood by others, and R5 sometimes understands others. R5's Care Plan with a date range of 9/1/23-11/30/23, with a target date of 1/17/24 states: Profile care guide . Interventions include I have a brace to my arms (alternating arms) to help with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-30 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not off each resident an influenza immunization. This affected 1 of 5 residents (R21) reviewed for immunizations of a total sample of 14. R21 did not receive influenza immunization. This is evidenced by: The Facilities Policy and Procedure entitled Guidelines for Influenza, Pneumococcal, & COVID-19 Immunizations dated 7/12/23 documents, in part: .1. Upon admission each resident/resident representative will be provided with information regarding the risk and benefits of influenza, pneumococcal, and COVID-19 immunization .4. Each resident/resident representative party will be provided annually with information regarding the risk and benefits of influenza vaccine and receive the immunization per their request, unless medically contraindicated .10. It will be documented if the resident refuses immunization or did not receive the immunization as a result of a medical contraindication . R21 is a short-term rehabilitation resident at this facility. R21 has 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.
“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 TRILOGY HEALTH SERVICES — 123 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 4.2 | -1.2 vs chain |
| Health inspection | 3 of 5 | 3.5 | -0.5 vs chain |
| Staffing | 2 of 5 | 3.3 | -1.3 vs chain |
| Quality measures | 4 of 5 | 4.8 | -0.8 vs chain |
The other 122 homes this chain runs (chain average 4.2★, per CMS)
Showing 40 of 122; 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
CMS ownership filings flag an owner of this facility as a real-estate investment trust (REIT). That’s a fact worth knowing: peer-reviewed research links private-equity and REIT ownership to lower staffing and more citations on average — though any individual home can run well or poorly regardless. Read the inspection and staffing record above on its own merits.
- AMERICAN HEALTHCARE REIT INC — REIT · 100.00% share · 5% Or Greater Indirect Ownership Interest
- TRILOGY REAL ESTATE INVESTMENT TRUST — REIT · 100.00% share · 5% Or Greater Indirect Ownership Interest
Source: CMS SNF ownership filings (PECOS). These flags are self-reported and undercount — federal auditors (GAO) and researchers find CMS captures only a fraction of true private-equity and REIT ties, so the absence of a flag on other homes is not proof they lack investor owners. How investor ownership affects care →
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CONTINENTAL MERGER SUB LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 26% | since 03/01/2023 |
| BARNEY, LEIGH | Individual | MANAGING CONTROL - GOVERNING BODY; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 01/01/2026 |
| CONNER, GREGORY | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2026 |
| DAVIS, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2026 |
| MCNAMARA, DONALD | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2026 |
| MEHAFFEY, TODD | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2026 |
| PIETROWSKI, CRISTINA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2026 |
| PROSKY, DANNY | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2026 |
| WILLHITE, GABRIEL | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 03/01/2023 |
| CHAPKO, ERIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/03/2026 |
| CORBIN, KATHY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2023 |
| FIGHTMASTER, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2023 |
| SIDHU, SARFRAZ | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/26/2026 |
| AMERICAN HEALTHCARE REIT HOLDINGS LP | Organization | ADP OF THE SNF | — | since 03/01/2023 |
| AMERICAN HEALTHCARE REIT INC | Organization | ADP OF THE SNF | — | since 03/01/2023 |
| GAHC3 TRILOGY JV LLC | Organization | ADP OF THE SNF | — | since 01/01/2026 |
| GAHC4 TRILOGY JV LLC | Organization | ADP OF THE SNF | — | since 01/01/2026 |
| TRILOGY INVESTORS LLC | Organization | ADP OF THE SNF | — | since 01/01/2026 |
| TRILOGY MANAGEMENT SERVICES LLC | Organization | ADP OF THE SNF | — | since 07/15/2025 |
| TRILOGY REAL ESTATE INVESTMENT TRUST | Organization | ADP OF THE SNF | — | since 01/01/2026 |
| TRILOGY REIT HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 01/01/2026 |
CMS files one row per role, so the 26 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $329K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525380. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-01, 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.