Tomah Nursing And Rehab
1505 Butts Ave, Tomah, WI 54660 · For profit - Limited Liability company · 74 certified beds · (608) 372-3241 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- nursing-staff turnover (61%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 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 held steady at 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 | 14.0% | 16.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 12.9% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.7% | 2.7% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 9.4% | 5.7% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.6% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.8% | 18.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 12.4% | 16.9% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 92.2% | 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 | 15.8% | 24.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.3% | 15.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.8% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 63.5% | 82.2% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 12.2% | 23.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 17.9% | 15.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.06 | 1.66 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.62 | 2.29 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
55.8% 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 71 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.2% 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 41 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 0.31 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% 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 | 55.8%CMS range 46.0–66.9 | 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 | 9.1%CMS range 6.4–13.2 | 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 | 51.2% | 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 | 41.5% | 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 | 46.3% | 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 | 87.5% | 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 | 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 | 0.0% | 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 | 8.9% | 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 | 7.2%CMS range 3.6–12.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 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 74 beds and averages 48.7 residents a day — about 66% occupied, or roughly 25 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 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 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 2.99 hrs/resident/day on weekends vs 3.55 on weekdays — 16% thinner on weekends. RN hours go from 0.84 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 61% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-12-22 · 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 a resident's environment remained as free of accident hazards as possible for 5 of 8 residents (R3, R7, R9, R10, and R11) by failing to have a system in place for monitoring the surface temperature of baseboard heaters to prevent burns. R3 is a resident with impaired mobility and cognition. On 10/29/25, R3 fell out of bed onto the baseboard heater. R3 was stuck between the wall and the bed. R3 sustained partial thickness (2nd Degree) burns. R7 is a resident with impaired mobility, who was observed by Surveyors to have her bed next to the baseboard heater, with the foot of the bed touching the baseboard heater, and the head of the bed less than 6 inches away from the baseboard heater. R7's base board heater temperature was 130.6. R7 has had a prior fall out of bed. The facility's failure to have a system in place for monitoring the surface temperature of baseboard heaters to prevent burns created a reasonable likelihood for serious…
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 before2026-01-26 · 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 failed to thoroughly investigate an allegation of misappropriation for 1 of 2 abuse allegations (R1). On 1/16/26 R1 reported to CNA C (Certified Nursing Assistant) that she was having pain after CNA C assisted her with cares. CNA C reported R1's concern to RN D (Registered Nurse). R1 told RN D, That CNA was rough and She didn't mean to hurt me. R1 was sent to the ED (emergency department). The ED physician indicated, I suspect that R1 likely has a right elbow sprain. The facility failed to interview other residents to determine the scope of the concern. Therefore, this incident has not been thoroughly investigated. This is evidenced by:Facility policy, titled Abuse Prevention Program Policy and Procedure, includes: Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse. Neglect is defined as the failure of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-01-13 · 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 48 residents who reside in the facility.Surveyor observed dishwashing process. Dietary Aide failed to ensure proper hand washing was complete before going from dirty items to clean items in the kitchen.Evidence by:The facility policy, Machine Dishwashing Racking Procedure, Reviewed 1/25, states, in part;.To prevent cross-contamination when one employee is operating the dish machine, strict hand washing procedures must be adhered to between the soiled dish and clean dish handling.The facility policy, Hand washing/Hand Hygiene, Reviewed 1/25, states, in part;.Procedure:.3. Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice.On 1/12/26 at 8:54 AM, Surveyor observed dishwashing. Surveyor observed two staff assisting with dishwashing, one was assigned to the dirty dishes and the other staff assigned to clean dishes. Dietary Aide…
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 · F2026-01-13 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
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 garbage and refuse was disposed of properly. This has the potential to affect all 48 residents who reside at the facility.Surveyor observed the facility's main dumpster lid open and garbage outside of the dumpster. Surveyor observed a garbage bag, multiple disposable gloves, a hairnet, food wrappers, and cardboard outside of the dumpster.Evidenced by:The facility policy, Sanitizing Garbage Cans and Dumpsters, Revised 1/25, states, in part;.8. Dumpsters provided by the local refuge vender will be maintained by the facility and kept covered at all times. 9. Area around the dumpster will be kept clean, free of debris, foul odors, and free of harboring/feeding of pests.On 1/7/26 at 10:06 AM, During the initial walk through of the kitchen, Surveyor observed the facility dumpsters. Surveyor and Dietary Manager K (DM) observed the dumpster lid open and a garbage bag, multiple disposable gloves, a hairnet, food wrappers, and cardboard outside of the dumpster. DM K indicated it is everyone's responsibility…
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 before2026-01-13 · 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, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials including the State Survey Agency for 2 of 2 incidents (R10 & R5) reviewed. R10 voiced an allegation of neglect to CNA O (Certified Nursing Assistant) of being left in her wheelchair for around 6 hours, left in a wet brief, left without colostomy care, and left without a call light or a way to summons assistance. The facility failed to follow the facility's abuse policy and failed to report allegation to NHA A and to state agency. R5 reported an allegation of abuse via a grievance form. The facility failed to report the allegation of abuse to the State Agency. Evidenced by: Facility policy, titled Abuse Prevention Program Policy and Procedure, includes: Each resident has…
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 before2026-01-13 · 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 that in response to allegations of abuse, neglect, exploitation or mistreatment, that all alleged violations are thoroughly investigated for 1 of 2 sampled Residents (R10). R10 voiced an allegation of neglect to CNA O (Certified Nursing Assistant). The facility failed to investigate the allegation thoroughly, including gathering staff interviews, gathering resident interviews, and recording an interview with R10. Evidenced by: Facility policy, titled Abuse Prevention Program Policy and Procedure, includes: Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Abuse also includes 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 · D2026-01-13 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 had a baseline care plan developed and implemented, within 48 hours, with needed instructions to provide effective and person-centered care for 1 of 6 residents (R5) reviewed. R5's baseline care plan did not include R5's diagnosis of PTSD (Post- traumatic stress disorder), triggers, or interventions.Evidenced by:The facility's policy titled Resident Baseline Care Plan Development updated on 1/17/18 states in part .Policy: The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person- centered care of the resident that meet professional standards of quality care. The baseline care plan must-.ii. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- .e. Social Services.R5 was admitted to the facility on [DATE] with diagnoses that include PTSD (Post -traumatic stress disorder),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-13 · 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 (R5) reviewed for dialysis. 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 policy titled Dialysis Services last reviewed on 1/2025 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 outside of the dialysis facility, but occasionally, they rupture at…
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 · D2026-01-13 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure 1 of 1 resident (R5) who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. R5 has a diagnosis of PTSD (Post Traumatic Stress Disorder) and does not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions.Evidenced by:The facility's policy titled Trauma Informed Care revised 9/2022 states in part, .Policy Explanation and Compliance Guidelines: .2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as 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 · D2026-01-13 · 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 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 (R13) of 5 residents reviewed for medications.R13 was prescribed Buspirone for anxiety and failed to receive the medication.This is evidenced by:The facility's policy Care Standards, Standards of Nursing Practices, dated 1/25, includes: Responsibility with Medications and Physicians Orders 1. The licensed nurse that receives an order and notes the order is responsible to carry the order through by placing in achieve [Electronic Health Record], on the MAR (Medication Administration Record), TAR (Treatment Administration Record), ordering the medication from pharmacy, communicating order specifics to appropriate departments.R13 admitted to the facility on [DATE] with diagnoses including other symptoms and signs involving cognitive functions and awareness,…
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 · D2026-01-13 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility did not ensure it was free of medication error rates of 5% or greater. There were 8 errors in 25 opportunities that affected 1 resident (R50) out of a sample of 5 residents observed for medication administration. This results in an error rate of 16%. R50's medications were scheduled for 6:00 PM- 10:00 PM and R50 received their medications at 4:10 PM. Additionally, R50 was administered the wrong dose of hydroxyzine. Evidenced by: The facility's policy titled Medication Administration Procedures dated 4/2020 states in part A. Designated Times: .4. All medications must be passed within one hour on either side of the designated time.B. Dosage: 1. Give the exact number of tablets/ capsuled ordered. On 1/8/26 at 4:10 PM, Surveyor observed RN N (Registered Nurse) administer medications to R50. Surveyor observed RN N administer the following medications: Klor-Con 20 mEq (milliequivalent) 1 tablet, levetiracetam 1000mg (milligrams) 1 tablet, tamsulosin hydrochloride 0.4 mg oral capsule, and hydroxyzine hydrochloride 25 mg…
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 16 citations
- Potential for harm · D2025-09-23 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of professional standards of practice, the facility did not ensure that the services provided by nursing personnel met the professional standards of quality for 1 of 3 residents (R1).Facility received orders to get a UA (urinalysis) on R1. Facility did not obtain the UA for R1 as ordered by the physician.Evidenced by:Surveyor requested a copy of all policies that reflect following the physicians orders and what to do if unable to complete physicians orders. Facility was unable to provide Surveyor with a policy that addressed following physicians orders or what to do if unable to follow physicians orders.R1 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease, dementia without behavioral disturbance, psychotic disturbance, hypertension, edema, anxiety, major depressive disorder, personality disorder, and chronic pain.Nurses Note from 8/8/25 at 15:03 (3:03 PM) states, Family continues to express concerns about urinary urgency,…
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 before2025-06-11 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections such as COVID-19 and gastroenteritis. This had the potential to affect all 49 residents residing within the facility at the time of the outbreaks. As of 4/10/25 the facility was having a gastroenteritis outbreak with 3 staff with signs and symptoms. As of 4/20/25 the facility was having a COVID-19 outbreak with 4 residents positive for COVID-19. - Facility line listings were not completed contemporaneously. - Facility failed to recognize or ensure they routinely screened all residents for signs and symptoms of COVID-19 daily and increase screening to every shift once the outbreak was identified. - Facility did not have dates residents were removed from isolation precautions following COVID-19 positive test. - Facility did not recognize the gastroenteritis outbreak. - Facility did not ensure staff who had signs and symptoms of gastroenteritis did not return to work…
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 before2025-06-11 · 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
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 3 sampled residents (R) R8, reviewed for abuse. Facility did not report an allegation reported by R8 that Certified Nursing Assistant (CNA) I is always so rough and is giving R8 bruises to state survey agency or law enforcement. Evidenced by: The facility's Abuse Prevention 7 Components, Reviewed 01/2025, includes, in part, the following: VII. Reporting/Response: All alleged or suspected violations are to be reported immediately to the Administrator or Director of Nursing, which are responsible to notify required officials, including to the State Survey Agency, Adult Protective Services, Local Public Safety, Licensure Boards, Regional Director of Operations or Regional Clinical Directors (representative of governing board and any other agencies 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 before2025-06-11 · 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
Based on interview and record review, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for 2 of 3 residents (R) R1 and R8 reviewed for abuse. Facility did not fully investigate an allegation that Certified Nursing Assistant (CNA) I flipped R1 off when leaving R1's room and R1 does not feel safe with CNA I in his room. Facility did not fully investigate an allegation that CNA I was rough with R8 and left bruises. Evidenced by: The facility's Abuse Prevention Program 7 Component, Reviewed 01/2025, includes, in part, the following: V. Investigation. 1. The Administrator and or Director of Nursing are to initiate and coordinate completion of a thorough investigation. Investigations must be initiated immediately and concluded as soon as possible not to exceed (5) days. Forms are available to assist the investigator and may utilized. The investigation must include but not limited to: Identify alleged perpetrator, remove from resident care area immediately, suspended pending investigation conclusion, obtain state, ., Identify and begin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-10 · 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
Based on interview and record review, 1 of 3 sampled residents' (R1) care and treatment to heal stasis ulcers was not provided in accordance with professional standards. R1's treatments of venous stasis ulcers were not completed as ordered by the physician. This is evidenced by The facility policy and procedure entitled Skin Care dated last reviewed 01/25 states in part Initiate treatment in accordance with facility protocols, standing orders, or physician orders. R1 was admitted to the facility in January 2025 with diagnoses including chronic venous hypertension with ulcer of bilateral lower extremity, myocardial infarction, and type 2 diabetes mellitus. R1 has physician ordered treatments to right and left lower leg venous ulcers. Cleanse with NS (Normal Saline) pat dry. Apply skin prep to peri wounds. Apply Medihoney to wound beds, followed by Calcium Alginate. Place a double layer of ABD pads over wounds and secure with 2 kerlix gauze roll and secure with tape. Ensure that kerlix is going from toe to just below the knee and then wrap ACE on top of the kerlix to hold bandage 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 before2025-04-10 · 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
Based on interview and record review, 1 of 3 sampled residents (R) care and treatment of pressure ulcers was not provided in accordance with professional standards (R1). R1's pressure ulcer treatments were not completed as ordered. This is evidenced by: The facility policy and procedure titled Pressure Injury Prevention and Care, dated last reviewed 01/25, states in part: Initiate treatment in accordance with facility protocols, standing orders, or physician orders. R1 was admitted to the facility in January 2025 with diagnoses including pressure ulcer left heel, stage 3, chronic venous hypertension with ulcer of bilateral lower extremity, myocardial infarction, and type 2 diabetes mellitus. R1 has physician ordered treatments to Skin treatment to left heel, Cleanse wound with NS (Normal Saline), pat dry. Apply skin prep to peri-wound. Apply Medihoney to wound bed. Cover with ABD pad and secure with Kerlix gauze and tape. Then wrap from toes to knee with ACE wrap to hold dressing in place and prevent drainage from coming through for therapy purposes. Change daily and prn. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-11 · 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 new care planned fall interventions were implemented post falls to prevent accidents for 1 of 3 residents (R) R3, reviewed for falls. R3 was at risk for falls and had a fall on 09/16/24. Facility did not implement the new interventions put into place post fall. Findings include: Example 1: R3 was admitted to the facility on [DATE], then readmitted on [DATE], with diagnoses including multiple myeloma, gastroparesis, osteoporosis, dysphagia, weakness, collapsed vertebra, and fibromyalgia. R3's minimum data set (MDS) assessment, completed on 10/02/24, confirmed R3 scored 15 out of 15 during a brief interview for mental status (BIMS), indicating intact cognition. R3 was at risk for falls. R3 requires substantial maximal assistance from staff for toileting, sit to stand, transferring, dressing lower body, and putting on/taking off footwear. Surveyor reviewed R3's progress note dated late entry 09/18/24, which stated in part: .IDT note from fall on…
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 before2024-08-29 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility did not prepare, store or distribute foods in a safe and sanitary manner. The facility practices had the potential to affect all 49 residents. Facility kitchen staff did not maintain proper personal hygiene to prevent contamination. Facility kitchen staff did not store food and equipment properly and did not prevent food contamination. This is evidenced by: Surveyor reviewed the facility policy titled Dietary Dress Code which is dated as most recently revised on 08/23. The policy in part read: Policy: All dietary employees will wear clean and safe apparel. Beard covers must be worn by staff presenting with facial hair. Surveyor reviewed the facility policy titled Storage Procedures which is dated as most recently revised on 08/23. The policy in part read: Policy: Food shall be properly stored to preserve flavor, nutritive value and appearance. Dry bulk foods are to be stored in plastic containers with tight covers, or bins which are easily sanitized. The container should be clearly labeled. Open packages are to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-29 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 4 of 4 residents (R48, R16, R5 and R2) who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming, and personal hygiene. The facility did not assure R48, R5, and R16 were provided routine weekly minimum showers as part of their activities of daily living (ADL). The facility staff did not provide assistance with nutrition for R2 who is dependent on staff. This is evidenced by: The facility policy, entitled Activities of Daily Living (ADLs)/Maintain Abilities reviewed on 01/2024, states in part, 3. The facility will provide care and services for the following activities of daily living: a. Hygiene - bathing . Example 1 R48 was admitted to the facility on [DATE]. R48's Minimum Data Set (MDS) with a target date of 06/28/24, indicated that R48 has a Brief Interview for Mental Status (BIMS) of 4 (severe cognitive impairment), requires substantial/maximal assistance 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 · Ecited before2024-08-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 residents receive adequate supervision and assistive devices to prevent accidents for 5 of 5 residents reviewed (R22, R43, R39, R32, R1). R22 and R43 maintained their own smoking materials which is not consistent with the facility policy for smoking. Staff did not ensure R39 and R32 were smoking safely in designated areas. R39 maintained their own smoking materials. R43's Feeding Precautions were not implemented and placed R43 at risk for aspiration. Staff did not provide R1 with meal assistance for safety as directed in the plan of care. This is evidenced by: The facility policy entitled, Smoking Policy, dated 01/2024, states: -Supervised smoking times will be designated by the facility and posted. -Residents will be alerted at the scheduled smoke time and assisted to designated location. -All cigarettes, and e-cigarettes that are unsmoked will be returned to facility staff for storage. -Smoking material will be labeled and kept in 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 · D2024-08-29 · 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 observation, interview and record review, the facility did not ensure residents (R) were treated with respect and dignity and cared for in a manner to enhance their quality of life. Facility staff stood over R34 while assisting to eat. This affected 1 of 3 residents observed. Findings include: Facility policy entitled, RESIDENT RIGHTS, last revised January 2024, stated in part, It is the policy of this facility to ensure residents have the right to a dignified existence, self-determination, and communications with and access to persons and services inside and outside of this facility . R34 was admitted to the facility on [DATE] with diagnoses that include weakness, cognitive communication deficit, and diabetes. R34's Minimum Data Set (MDS), dated [DATE], stated that R34 required substantial/maximum assist with eating. On 08/26/24 at 12:57 PM, Surveyor observed Certified Nursing Assistant (CNA) N assisting R34 to eat their noon meal. CNA N stood on the left side of R34 during the entire time R34 was…
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 before2024-08-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility did not ensure 1 of 5 residents (R48) reviewed for high risk of pressure injury development, received the necessary treatment and services to promote healing of existing skin impairments. The facility did not ensure appropriate hand hygiene during wound care was conducted. This is evidenced by: The facility policy entitled Handwashing/Hand Hygiene last reviewed by facility on 01/2024 states in part: Practicing hand hygiene is a simple way to prevent infections by preventing the spread of germs. Wash hands and other skin surfaces when: 1. After immediate contamination with blood, other body fluids or potentially contaminated articles. 2. After removing gloves or other personal protective equipment. 4. Before and after nursing treatments or procedures (dressing changes). R48 was admitted to the facility on [DATE] and has diagnoses that include neutropenia (low white blood cell counts, which are a type of infection-fighting blood cell), type 2…
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 before2024-08-29 · 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases, and infections for 1 of 4 residents (R) observed. (R202) Facility staff did not wear a gown during high-contact care for a resident on enhanced barrier precautions (EBP). Facility staff did not sanitize lift after use on a resident with EBP. Findings include: Facility policy entitled, Enhanced Barrier Precautions, last revised April 2024, stated in part, .Personal protective equipment (PPE) for EBP is only necessary when performing high-contact care activities .includes, dressing, transferring, changing briefs, toileting . Facility policy entitled, CLEANING/DISINFECTING RESIDENT-CARE ITEMS AND EQUIPMENT, last revised January 2024, stated in part, .Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident .…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-28 · 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 staff interviews and record review, the facility did not thoroughly investigate, determine root-cause, document details, and provide satisfactory resolution for 1 of 3 residents (R) R1's grievances. Findings include: The facility's grievance policy, dated 01/2022, reads, in part, Residents have the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or fear of reprisal. Including grievances with respect to care and treatment, which has been furnished as well as have not been furnished, the inappropriate behavior of staff and of other residents, and any other concern regarding their stay. 4. Upon receipt of grievance, an immediate action will be implemented to prevent further potential violation of any resident right while the alleged violation is being investigated. 6. All grievances received will be investigated within 72 hours following receipt of the complaint, the facility will inform the complainant with the results in writing. R1 was…
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 · Ecited before2023-07-19 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility did not 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, infection, and Covid. This had the potential to affect 23 out of 38 residents (R) who resided on the Covid hall in the facility. The facility did not ensure staff wore the proper personal protective equipment (PPE) during a Covid outbreak in the facility. Universal Worker (UW) E was observed to pull their face mask down to speak to others multiple times, exposing their nose and mouth. This is evidenced by: The facility policy, entitled Isolation Categories of Transmission Based Precautions, dated 09/2022, stated in part: .To provide care to residents documented or suspected to be infected or colonized with highly transmissible microorganism that requires additional precautions beyond standard precautions, in order to reduce transmission of these microorganisms .The facility will implement a system to alert 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 · D2023-07-19 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility did not provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) for residents (R) whose Medicare Part A coverage was discontinued with benefit days remaining for 1 (R29) of 3 residents reviewed. R29 was discharged from Medicare Part A services with benefit days remaining and remained in the facility. The facility did not provide a SNFABN or NOMNC. This is evidenced by: The facility policy titled, Medicare Denial Notification SNFABN (CMS 10055) and NOMNC (CMS 10123), with a date of October 1, 2016, read in part, The original copy of the form is to be kept in the beneficiary's financial folder the form may be mailed certified to the family member or legal representative document your conversation - when was the call made, who did you talk to and any response. On 07/18/2023, Surveyor reviewed a random sample of 3 residents that discharged within the last six months from a Medicare covered Part A stay with benefit days remaining. While reviewing the SNFABN…
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 ATRIUM CENTERS — 26 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.0 | -1.0 vs chain |
| Health inspection | 2 of 5 | 2.7 | -0.7 vs chain |
| Staffing | 3 of 5 | 3.4 | -0.4 vs chain |
| Quality measures | 3 of 5 | 3.7 | -0.7 vs chain |
The other 25 homes this chain runs (chain average 3.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ORION OPERATING SERVICES LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/01/2007 |
| SHEA, BRANDI | Individual | W-2 MANAGING EMPLOYEE | — | since 03/09/2022 |
| LOCKHART, DENNIS | Individual | CORPORATE DIRECTOR | — | since 08/03/2003 |
| ALBRIGHT ROSS, SUSAN | Individual | CORPORATE OFFICER | — | since 12/24/2017 |
| BAILEY, ESSEL | Individual | CORPORATE OFFICER | — | since 08/03/2003 |
| FINNEY, DONALD | Individual | CORPORATE OFFICER | — | since 08/03/2003 |
| ROCCA, MICHAEL | Individual | CORPORATE OFFICER | — | since 06/14/2021 |
| ATRIUM CENTERS MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2007 |
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $752K paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525442. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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 →
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