Tomahawk Health Services
720 E Kings Rd, Tomahawk, WI 54487 · For profit - Corporation · 50 certified beds · (715) 453-2164 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
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.4% | 16.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 4.7% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 5.6% | 2.1% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.4% | 2.7% | 2.0% | better |
| Long-stay residents with depressive symptoms | 6.0% | 5.7% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.0% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 20.6% | 18.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 18.8% | 16.9% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.7% | 5.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.8% | 24.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.8% | 15.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 89.7% | 82.2% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.68 | 1.66 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.45 | 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.
57.8% 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 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% 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 | 57.8%CMS range 43.1–74.9 | 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 | 11.0%CMS range 7.3–16.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.80 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 50 beds and averages 43.8 residents a day — about 88% occupied, or roughly 6 beds typically open. It runs fairly full. 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 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.01 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 3.05 hrs/resident/day on weekends vs 3.71 on weekdays — 18% thinner on weekends. RN hours go from 1.22 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · J2026-04-01 · 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 each resident received adequate supervision and assistance devices to prevent elopement or falls for 2 of 3 residents reviewed (R23, R5).R23 has a history of elopement attempts on and was assessed to be at risk for wandering and elopement. R23 wears a Wanderguard that alerts staff to her attempts to elope. On 02/24/26, R23 exited the facility without staff knowledge and without the Wanderguard alarm sounding. R23 was found by a citizen approximately 0.7 miles from the facility with approximately 1 inch of snow on top of her head. Police were called and were able to determine resident was from the facility.The facility's failure to provide adequate supervision created a finding of immediate jeopardy that began on 02/24/26. Director of Nursing (DON) B was notified of the immediate jeopardy on 03/19/26 at 3:10 PM. The immediate jeopardy was removed on 3/19/26 however, the deficient practice continues at a scope/severity of D 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 · 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 and interviews, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. This had the potential to affect all 48 residents that eat orally. Prepared food placed in the walk-in cooler had been covered but was not labeled or dated, food in dry storage was not covered or dated, and 2 opened containers of milk were in milk cooler without indication of when they were open or when they should be used by resulting in the potential for foodborne illnesses to spread.Findings include:The facility's guidelines titled, Labeling and Dating dated 2017, states in part, All foods should be dated upon receipt before being stored. Food labels must include: the food item name. the date of preparation/receipt/removal from freezer, the use by date as outlined in attached guidelines. Guidelines assume that food is properly stored, covered, and handled. Guidelines apply, regardless of storage location.On 3/17/26 at approximately 8:30 AM, during initial kitchen tour, Surveyor interviewed Kitchen Account Manager V, who…
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 F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for all 44 residents in the facility.The facility failed to protect residents from risk of transmission of communicable disease as follows: No airborne precaution signs posted on residents diagnosed with COVID Certified nursing assistant (CNA) staff not using proper N95 masks when entering rooms of positive COVID residents PPE carts stocked with one size N95 masks for all staff to use, despite FIT testing recommendations. Staff not using proper PPE during catheter care Proper hand hygiene not being used during wound care Commercial washer and dryer temperatures not monitored/logged to ensure proper decontamination of soiled linens. Dirty linens not covered in a shared shower room and a resident with dementia observed rummaging through them…
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 · E2026-04-01 · tag F0658 — failed to meet professional standards of care — patternEnsure 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
Based on observations, interviews, and record review, the facility did not provide care adhering to accepted standards of practice for 4 of 5 residents reviewed. (R2, R6, R21, and R39)Faciity did not follow manufacturer guidelines for proper placement of continuous glucose monitoring device for R2, R6, R21, and R39.Nursing did not prime insulin pens before administering insulin to R2, R6, R39.Nursing administered a dose of Ferrous Sulfate to R21 without confirming with phsyician what the dose was. Order in R21's medical record did not state dosage. Example 1The facility policy with a revision date of 08/05/2022, titled, NSG - Blood Glucose Monitoring, states, The nurse will perform the blood glucose test utilizing the facility's glucometer as per manufacturer's instructions. On 03/17/26 at 9:28 AM. Surveyor noticed R2 was lying in bed with chest exposed and had a continuous glucometer sensor (Libre) applied to his/her upper left chest. Surveyor confirmed this with Licensed Practical Nurse (LPN) P who provided the manufacturer insert. According to the insert, it clearly stated 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 · E2026-04-01 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 observations, interviews, and record reviews, the facility did not ensure medication error rates are not 5 percent or greater for 4 of 5 residents reviewed during medication pass.The facility error rate was 22.22%. Example 1 The facility policy titled, Medication Orders, revised 01/23, states the elements of the medication orders include dose and dose form and any dose or order that appears inappropriate, considering the resident's age, condition, allergies or diagnosis, is verified by nursing with the prescriber. On 03/18/2026 at 7:25 AM, Surveyor observed LPN H administer Ferrous Sulfate to R21 without confirming the physician order contained a dosage for R21. R21's physician's orders dated 10/19/25 notes: Ferrous Sulfate one tablet by mouth every other day. Surveyor reviewed R21's notes and found that the dosage was not clarified with the physician. LPN H administered Ferrous Sulfate 325mg. There were no notes found in R21's record indicating the correct number of milligrams R21 was to receive. On 3/18/26 at 11:34 AM, Surveyor asked DON B what the expectation would be if…
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 F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility did not notify the physician as indicated by parameters in physicians' orders for a significant weight increase for 1 out of 13 residents (R) R46. This is evidenced by:R46 was admitted to the facility 12/21/21 with a diagnosis that included atrial fibrillation. R46 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitively intact.R46's Quarterly Minimum Data Set (MDS) with an end date of 2/26/26, Section K: weight 128#.R46's care plan initiated 2/24/26, with a target date of 4/18/26, states, Actual dehydration or risk for alteration in hydration related to diuretic use. Goal: Will maintain adequate hydration as evidenced by good skin turgor, moist oral mucosa, and stable weights. R46 was hospitalized , diagnosed with congestive heart failure (CHF), and on 2/20/26 Furosemide, a diuretic, was prescribed 20 MG by mouth every morning.R46's physician orders dated 2/25/26 is as follows: daily weights, call Medical Doctor (MD) if weight change of 3 pounds in 1 day or greater than 7 pounds in one week, one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- 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 failed to report events which had the potential to cause serious harm or injury for 1 of 3 residents reviewed (R23).R23 is cognitively impaired, eloped without facility knowledge, and the alarm system was not working properly.Findings include:R23 was admitted to the facility on [DATE].Most recent Minimum Data Set (MDS) assessment indicates a Brief Interview for Mental Status (BIMS) score of 00/15, indicating severe cognitive impairment.On 02/24/26 at approximately 12:50 PM, R23 was observed walking around the parking lot of a local thrift store by reporting party (RP) D. RP D called Police Officer (PO) C who responded shortly after. R23 was reported to have about an inch of snow on top of R23's head. PO C called Emergency Medical Services (EMS) who assisted in taking R23 to the hospital for evaluation. The facility was contacted and asked if they were aware R23 was not in the facility. The facility was not aware R23 had left. R23 had a Wanderguard bracelet 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 · D2026-04-01 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide written information specifying bed-hold duration and payment policy to the resident or resident representative for 1 resident (R49) for 3 residents reviewed for bed-hold information in a sample of 13 residents. The facility failed to provide a written bed-hold agreement to R49's legal representative upon transfer to the emergency department (ED), or within 24 hours of transfer to the ED, or document in R49's medical record that bed-hold information was provided to a legal representative. This resulted in R49's legal representative to be uninformed of cost to resident to hold R49's bed, if desired, during R49's hospitalization. Findings include:The facility policy, titled Bed Hold Notice, last revised on [DATE], states in part: As part of the admission packet and at the time of a transfer to the hospital.the facility will provide the resident and/or resident representative written information that specifies.the duration of the State bed-hold…
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 F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not implement the comprehensive care plan for accident prevention for 2 residents (R5, R43) of 3 residents reviewed for accidents in a sample of 13 residents. The facility did not implement care plan intervention of R5 always wearing grip socks or shoes when ambulating to prevent falls from occurring. This could result in R5 falling and sustaining serious physical injury.The facility did not implement care plan intervention providing gripper strips at R43's bedside to prevent falls when getting self out of bed. Findings include:The facility policy, titled Fall Prevention and Management Guidelines, last revised 07/18/2024, states in part: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury.Example 1R5 was admitted to the facility on [DATE] and has diagnoses that include post-traumatic…
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 F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility did not revise resident's care plan following the completion of a Minimum Data Set (MDS) assessment for 1 of 13 residents reviewed. R2's care plan notes that R2 receives opioids, foot care, daily feet inspections, blue boot to right foot, hand splints, and assist with urinal. R2 is a double amputee, is no longer receiving opioids, refuses hand splints, and has a Foley catheter in place.R2 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, contractures of both hands and knees due to palmar fascial fibromatosis, left below the knee amputation, cervical neck pain, bow back pain, neuropathy, enlarged prostate, and urinary retention. R2's Minimum Data Set (MDS) dated [DATE] indicates R2 uses an indwelling Foley catheter. R2's most recent Brief Interview of Mental Status (BIMS) score, dated 03/16/26, was 8 of 15 indicating moderately impaired cognition. On 03/17/2026 at 9:00 AM, Surveyor observed R2 lying in bed. R2…
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 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 residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident reviewed (R7).Facility staff did not obtain weights and vitals prior to or after dialysis appointments on several occasionsFindings include:Facility Policy titled, Hemodialysis, last revised 09/10/23, reads in part: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goas and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.The licensed nurse will communicate to the dialysis facility by utilizing the Pre-Dialysis Communication assessment, that will include.vital signs.documentation of weights.R7 was admitted to the facility 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.
Show the remaining 14 citations
- Potential for harm · F2025-01-15 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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 follow the menu and did not notify residents of the menu change. This had the potential to affect all 43 residents in the facility. -The facility served a different meal than what was noted on the menu. The facility did notify residents of the menu change. -This resulted in residents complaining of the menu change. -This resulted in one resident (R28) requesting a bowl of cereal for lunch as he did not want what was posted on the menu. R28 was not notified of the menu change and was not given the option to receive the meal that was served. Findings: The facility's policy titled Menus, read in part, Menus will be planned in advance. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Menus will be posted in the Dining Services department, dining rooms, and resident/patient care areas. On 01/13/25, Surveyor noted the lunch menu was Chinese Pork Chop Suey with egg rolls, fried rice, and diced pears. On 01/13/25 at 11:53 AM, Surveyor observed R41's meal tray and noted she…
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 · D2025-01-15 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 promote and facilitate resident self-determination through support of resident choice and preferences for 1 of 12 residents (R) reviewed. (R1). R1 was not given the right to choose to receive meal textures that R1 requested and prefers. This is significant to R1. This is evidenced by: According to Wisconsin State Statute GUIDANCE §483.60(d)(1)-(2) includes, in part, Providing palatable, attractive, and appetizing food and drink to residents can help to encourage residents to increase the amount they eat and drink. Improved nutrition and hydration status can help prevent, or aid in the recovery from, illness or injury. R1 was admitted to the facility on [DATE] for rehabilitation after falling and fracturing the right knee. Diagnosis included right knee fracture, protein-calorie malnutrition, type 2 diabetes mellitus, and adult failure to thrive. R1's Minimum Data Set (MDS) assessment, completed on 12/03/24, confirmed R1 scored 15/15 during…
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 · D2025-01-15 · tag F0571 — isolatedLimit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
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 charged a resident for a service covered under Medicaid. This effected 1 of 5 sampled residents (R41). -The facility charged R41 for transportation services to a medical appointment, which is a covered service under Medicaid. -The facility charged R41 for transportation services which were not specifically requested by R41. -The facility did not inform R41, orally and in writing, of a charge for a service and what that charge would be. Findings: R41 was admitted to the facility on [DATE], with diagnoses including anemia, atrial fibrillation, and multiple myeloma. R41 scored 12/14 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R41's daughter assists R41 with her personal funds. R41's physician orders included an order for apixaban, a medication to prevent blood clots. On 01/13/25 at 12:47 PM, Surveyor interviewed R41. R41 stated, Last week I had an appointment, and their van driver was not available. They called my son-in-law, but…
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 before2025-01-15 · 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 residents received treatment and care in accordance with professional standards of practice for 1 of 12 sampled residents (R1). The facility did not follow hospital discharge orders to complete daily blood glucose testing to ensure safe blood sugar levels. Findings: R1 was admitted to the facility on [DATE] for rehabilitation after falling and fracturing the right knee. Diagnoses included right knee fracture, protein-calorie malnutrition, type 2 diabetes mellitus, and long-term use of oral hypoglycemic drugs. R1's Minimum Data Set (MDS) assessment, completed on 12/03/24, confirmed R1 scored 15/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. On 11/22/24, R1's history and physical note indicates R1 developed hypotension and was sent to the emergency room. R1 was admitted to the hospital from [DATE]-[DATE]. The hospital discharge summary revealed R1's diagnoses included sepsis, UTI, acute kidney injury, and 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 before2025-01-15 · 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 infections for 1 out of 8 residents on Enhanced Barrier Precautions (R23), staff did not change gloves or perform hand hygiene during observation of wound care. This is evidenced by: Facility policy titled, Enhanced Barrier Precautions, with most recent revised date of 08/08/24, stated in part: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities .high-contact resident care activities include: .wound care: any chronic skin opening requiring a dressing. R23 was admitted to the facility on [DATE] with pertinent diagnoses of Multiple Sclerosis (MS) 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 · Ecited before2023-11-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 store, prepare, distribute, and serve food by professional standards for food service safety. The facility distributed to residents eating in their rooms food that was uncovered and exposed to possible contamination. This has the potential to affect all 17 of 39 residents (R) (R36, R26, R3, R16, R25, R22, R31, R30, R24, R33, R18, R5, R28, R21, R10, R6, R19). Findings include: The facility policy, entitled Meal Distribution, dated September of 2017, states in part: 3. All foods that are transported to dining areas that are not adjacent to the kitchen will be covered. On 11/20/23 at 11:51 AM, Surveyor observed a lunch cart being delivered to the hallway labeled MCU that was on precautions due to COVID-19. All residents were served down this hallway and not in the main dining adjacent to the kitchen. Strawberry shortcake was served, and all desserts were uncovered. Residents residing down this hallway were: R36, R26, R3, R16, R25, R22, R31, R30, R24, R33, R18. On 11/20/23 at 12:10 PM, Surveyor observed lunch trays…
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 before2023-11-22 · 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 staff did not perform hand hygiene when warranted, did not follow current standards of practice for Transmission-based Precautions (TBP), and did not offer hand hygiene to residents prior to eating. This facility practice has the potential to affect 9 residents (R24, R26, R36, R16, R30, R31, R18, R22, and R24) who reside in the Alzheimer Care Unit (ACU). This is evidenced by: Example 1 On 11/20/23 at 11:48 p.m., Surveyor observed Certified Nursing Assistant (CNA) P assist residents with lunch meal in ACU unit by delivering meal trays to residents in rooms and those eating in the common dining room (R24, R36, R16, R22, and R31). Surveyor observed CNA P open food cart, pull out residents' meal trays for service, deliver food trays to residents without completing hand hygiene before, during, or after meal service delivery. CNA P sat down with R24 to assist with feeding. CNA P did not complete hand hygiene prior to assisting R24 with meal. Surveyor observed CNA P leave R24 at dining table to assist other residents (R26 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-22 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure that each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 residents reviewed for restraints (R21). R21 had a pommel cushion without a physician order for use, the medical symptom the cushion is being used to treat or an assessment to determine appropriateness of its use. Furthermore, the device was not indicated in R21's care plan. The facility did not consider this device as being a potential restraint. This is evidenced by: The facility's policy titled Restraint Free Environment dated 9/22/22 was reviewed. The policy states, It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .Physical Restraint…
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 · D2023-11-22 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility did not complete and submit a Significant Change in Status (SCS) Minimum Data Set Assessment (MDSA) within 14 days after determining a SCS has occurred for 1 of 13 residents (R27) reviewed for assessments. This is evidenced by: R27 has medical diagnoses that include, but are not limited to, chronic obstructive pulmonary disease, protein-calorie malnutrition, diabetes mellitus-type II with neuropathy and peripheral vascular disease. In reviewing the Medical Record of R27, Surveyor noted the most recent MDSA completed was a quarterly assessment with the Assessment Reference Date of 8/27/23. R27 was admitted to hospice services 9/27/23 in which a SCS MDSA had not yet been completed. On 11/21/23 at 1:55 PM, Surveyor telephoned Staff C, who is the Corporate Director of Clinical Reimbursement. Staff C stated that Staff C oversees the MDS schedules, insurance updates and has direct discussions with the facilities regarding changes in residents that would constitute a significant change assessment. Staff C stated that she is the main…
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 · D2023-11-22 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility did not provide an ongoing individualized and meaningful program to support the residents in their choice of activities designed to meet their interests and support their physical, mental, and psychosocial well-being causing decreased social interaction. This affected 1 of 5 residents (R6) reviewed for activity programming. Findings include: R6 was admitted to the facility on [DATE]. Diagnoses include past medical history significant for depression, post-traumatic stress disorder (PTSD), history of opioid and alcohol dependence, chronic pain syndrome, and left below the knee amputation (BKA). R6's Minimum Data Set (MDS) assessment, showed R6 scored 13/15 during Brief Interview for Mental Status (BIMS) indicating intact cognition. PHQ-9 (mental health screening) confirmed mild depressive symptoms, with scores worsening from 6/27 to 7/27 since admission. R6's physician orders confirmed he was prescribed an anti-depressant and antipsychotic for…
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 before2023-11-22 · 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 residents receive treatment and care in accordance with professional standards of practice. A bowel regimen to prevent constipation was not implemented for 1 of 4 residents (R6). Findings include: R6 was admitted to the facility on [DATE] with a diagnosis of chronic pain syndrome. R6's physician orders indicated he received hydrocodone-Acetaminophen 7.5-325 mg three times daily for chronic pain, Dulcolax suppository 10 mg every 24 hours as needed for constipation, Milk of Magnesia 30 mL every 24 hours as needed for constipation, Senna Plus 8.6-50 mg every 24 hours as needed for constipation. R6's care plan included opioid use related Chronic Pain Syndrome, dated 06/07/23. Interventions included administer medications as ordered, monitor bowel habits and implement bowel regimen as ordered. R6's Minimum Data Set (MDS) assessment, dated 09/11/23, confirmed R6 is occasionally incontinent of bowel. Surveyor reviewed R6's bowel tracking…
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 · D2023-11-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview and record review the facility did not ensure R21's bladder continence program was followed , when toileting was not offered to R21. This is evidenced by: R21 has medical diagnoses that include, but are not limited to, severe dementia with behavioral disturbance, repeated falls, anxiety disorder and hypersexuality. The most recent Minimum Data Set Assessment (MDSA) was a Significant Change in Status assessment dated [DATE]. According to this assessment, R21 was scored a 4/15 on the Basic Interview of Mental Status (BIMS), indicating severe cognitive deficit. R21 also requires extensive staff assistance to meet her most basic daily tasks of bed mobility, transfers, dressing, personal hygiene, toileting and bathing. R21 was also listed as being non-ambulatory with no range of motion limitations and is frequently incontinent of bladder and bowel function. Surveyor reviewed the Comprehensive Care Plan (CCP) for R21 and noted the following problem areas: 1. Resident is incontinent of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure 1 of 4 residents reviewed for nutrition (R21), maintained acceptable parameters of nutrition, such as body weight. This is evidenced by: R21 has medical diagnoses that include, but are not limited to, severe dementia with behavioral disturbance, repeated falls, anxiety disorder and hypersexuality. The most recent Minimum Data Set Assessment (MDSA) was a Significant Change in Status assessment dated [DATE]. According to this assessment, R21 was scored a 4/15 on the Basic Interview of Mental Status (BIMS), indicating severe cognitive deficit. R21 also requires extensive staff assistance to meet her most basic daily tasks of bed mobility, transfers, dressing, personal hygiene, toileting and bathing. R21 required supervision with meals once the meal tray was set up. Surveyor then reviewed the Comprehensive Care Plan developed for R21 and noted the following problem: At risk for nutritional status change related to dementia, chronic…
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 · D2023-11-22 · 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 observations, interviews and record reviews, the facility did not ensure residents who are trauma survivors receive trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization for 1 of 1 resident (R6) reviewed for trauma informed care. Findings include: According to Substance Abuse and Mental Health Services Administration (SAMSHA) the principles of trauma-informed care must be addressed and applied purposefully. The following principles pertaining to trauma-informed care have been adapted from SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach, located at https://store.samhsa.gov/system/files/sma14-4884.pdf Safety - Ensuring residents have a sense of emotional and physical safety. Trustworthiness and transparency - Efforts to establish a relationship based on trust, and clear and open communication between the staff and the resident. Peer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to NORTH SHORE HEALTHCARE — 59 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.7 | -0.7 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 4 of 5 | 3.4 | +0.6 vs chain |
| Quality measures | 3 of 5 | 2.5 | +0.5 vs chain |
The other 58 homes this chain runs (chain average 2.7★, per CMS)
Showing 40 of 58; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NSHC WISCONSIN LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 05/14/2025 |
| CIBC BANK USA | Organization | 5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/31/2024 |
| BAUMANN, TROY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2016 |
| HOEHN, JEFFREY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2016 |
| CLIFTONLARSONALLEN LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/14/2025 |
| CONTINUUM THERAPY PARTNERS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2025 |
| NORTH SHORE HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/14/2025 |
| NSH REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2025 |
| WIPFLI LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2025 |
| BELONGIA, CHRISTINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2019 |
| GEE, DARREN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/30/2021 |
| GREER, LAUREN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/29/2023 |
| HEIKKINEN, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/17/2021 |
| HOSTETLER, HARRY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2023 |
| PATZER, COLLEEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/14/2023 |
| PURTELL, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2018 |
| GPH TOMAHAWK GOLDEN AGE LLC | Organization | ADP OF THE SNF | — | since 12/01/2016 |
CMS files one row per role, so the 35 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $246K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525334. 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 →
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