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Hamilton Health Services

1 Hamilton Dr, Two Rivers, WI 54241 · For profit - Corporation · 125 certified beds · (920) 793-2261 Medicare & Medicaid certified

Call the home — (920) 793-2261 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jan 2026Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2219 Garfield St · (920) 793-2281 · Call to confirm hours
Pharmacy
2219 Garfield St · (920) 794-8029 · Call to confirm hours
Grocery
1010 22nd St · (920) 793-2266 · Call to confirm hours
Park
2201 Polk St · Typically dawn to dusk
Place of worship

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 2 of 5
Long-stay residentspeople who live here 2 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 improved from 1 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.5%16.1%15.4%better
Long-stay residents who lose too much weight1.8%5.1%5.4%better
Long-stay residents with a catheter left in their bladder3.5%2.1%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection5.9%2.7%2.0%worse
Long-stay residents with depressive symptoms3.1%5.7%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.0%3.3%3.3%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication10.3%16.9%18.9%better
Long-stay residents given the seasonal flu vaccine81.0%95.0%95.3%worse
Long-stay residents with pressure ulcers8.2%5.0%4.7%worse
Long-stay residents with worsening bladder/bowel control29.6%24.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table24.5%15.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine47.6%82.2%79.4%worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

49.2% 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 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.2%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
0.28U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 46% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.2%CMS range 33.4–63.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 7.1–17.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identifiednot 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 settingnot 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 dischargenot 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 staynot 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 worsenednot 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 hospitalizationnot 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 SNFs1.101.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.20
RN hours/ resident / day
0.56
LPN hours/ resident / day
2.23
Aide hours/ resident / day
3.98
Total nurse hours/ resident / day
0.84
RN hoursweekends
42.1%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 125 beds and averages 21.0 residents a day — about 17% occupied, or roughly 104 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 3.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.20 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 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 3.60 hrs/resident/day on weekends vs 4.14 on weekdays — 13% thinner on weekends. RN hours go from 1.34 to 0.84 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% 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

1
deficiencies at the latest standard inspection (2026-01-28)
9
at the previous standard inspection (2024-09-11)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · Gcited before2024-07-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not provide adequate supervision for 1 resident (R) (R1) of 4 sampled residents. The failure to supervise R1 led to R1 being able to verbally and physically abuse another resident, R2. On 5/23/24, staff observed R1 exit R2's room and state, I'm going to kick your ass. R2 reported to staff that R1 had thrown a Styrofoam cup of coffee creamers at R2. Following the incident, the facility did not implement any interventions to ensure the safety of R1, R2, or other residents. On 5/24/24, Licensed Practical Nurse (LPN)-D observed R1 in the hallway outside R2's room. R1 appeared agitated and was repeatedly stating, Shut the f* up. LPN-D did not attempt to redirect R1 or implement any interventions to supervise R1 before LPN-D left the area. R1 then entered R2's room, threw a basket full of items which hit R2 in the forehead, and stated, That's what you get you f bitch. R2 was tearful and incurred redness and swelling on R2's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-28 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and record review, the facility did not report an allegation of exploitation to the State Agency (SA) for 1 resident (R) (R14) of 2 sampled residents.The facility was informed on 1/7/26 that Licensed Practical Nurse (LPN)-F accepted money from R14. The facility did not report the allegation of exploitation to the SA.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion .Reporting/Response: Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies(e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-28 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 thoroughly investigate an allegation of exploitation for 1 resident (R) (R14) of 2 sampled residents.The facility was informed on 1/7/26 that Licensed Practical Nurse (LPN)-F accepted money from R14. The facility did not thoroughly investigate the allegation of exploitation.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion .Investigation of Alleged Abuse, Neglect and Exploitation: .An immediate investigation is warranted when allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur .Written procedures 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-28 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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, staff and resident interview, and record review, the facility did not ensure food was palatable and served at an appetizing temperature for 1 resident (R) (R6) of 5 sampled residents.During observations of meal service, food held in the steam table and reheated food served to residents did not reach or maintain palatable temperatures.Findings include: The 2022 Food and Drug Administration (FDA) Food Code documents at 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S 3-501.19, and except as specified under (B) and in (C) of this section, Potentially Hazardous Food (Time/Temperature Control for Safety Food) shall be maintained: (1) At 57 Celsius (C) (135 Fahrenheit (F)) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11 (B) or reheated as specified in 3-403.11 (E) may be held at 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-11 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were coded correctly for 6 residents (R) (R23, R20, R12, R11, R24, and R13) of 12 sampled residents. R23 had a tracheostomy. R23's MDS assessments, dated 1/23/24, 4/24/24, 7/25/25, 8/27/24, and 9/16/24, did not indicate R23 received tracheostomy care. R12 was discharged from Hospice services on 5/12/24. R12's MDS assessments, dated 5/24/24 and 8/24/24, indicated R12 still received Hospice services. R20 was prescribed antiplatelet medication. R20's MDS assessments, dated 9/25/23, 12/26/23, 3/26/24, 6/26/24, and 8/27/24 did not indicate R20 received antiplatelet medication. In addition, R20 had a Preadmission Screening and Resident Review (PASRR) Level II Screen completed on 10/26/23. R20's MDS assessment, dated 8/27/24, indicated a PASRR Level II Screen was not completed. R11 was prescribed antianxiety medication. R11's MDS assessment, dated 8/14/24, did not indicate R11 received antianxiety medication. R24…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-11 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Between 9/9/24 and 9/11/24, Surveyor reviewed R13's medial record. R13 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes, hypertension, dementia, post-traumatic stress disorder (PTSD), depression, and anxiety. Surveyor reviewed R13's monthly pharmacy recommendations from October 2023 to the present. A monthly pharmacy review, dated 11/22/23, indicated the pharmacist made a recommendation to address R13's chlorhexidine administration, warfarin monitoring, Levemir and metformin monitoring, and Zoloft and trazodone monitoring. The facility was unable to provide a physician's response to the recommendation. A monthly pharmacy review, dated 12/29/23, indicated the pharmacist made a recommendation to address R13's as needed (PRN) diazepam use. The facility was unable to provide a physician's response to the recommendation. A monthly pharmacy review, dated 2/27/24, indicated the pharmacist made a recommendation to address R13's sucralfate use. The facility was unable to provide 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-11 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure written notification of coverage change and the financial liability for continued stay at the facility was provided when Medicare Part A benefits ended for 2 residents (R) (R26 and R10) of 5 sampled residents. The facility did not provide R26 with an Advanced Beneficiary Notice (ABN) form that contained the daily rate for which R26 was liable if R26 chose to remain in the facility after R26's Medicare Part A benefits ended. The facility did not provide a Notice of Medicare Non-Coverage (NOMNC) form (used to inform Medicare beneficiaries when their covered services are ending and their appeal rights) to R10 when R10's Medicare Part A benefits ended. Findings include: The Centers for Medicare and Medicaid Services (CMS)-10123 form indicates a Notice of Medicare Non-Coverage (NOMNC) form must be delivered at least two calendar days before Medicare-covered services end or the second to last day of service if care is not being provided daily.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-11 · tag F0637 — isolated
    Assess 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 staff interview and record review, the facility did not ensure a Significant Change Minimum Data Set (MDS) assessment was completed for 1 resident (R) (R12) of 12 sampled residents. The facility did not complete a Significant Change MDS assessment when R12 discharged from Hospice services. Findings include: Between 9/9/24 and 9/11/24, Surveyor reviewed R12's medical record. R12 was admitted to the facility on Hospice services on 11/16/23 with diagnoses including diffuse large B-cell lymphoma and encounter for palliative care. R12's medical record indicated: ~ R12 discharged from Hospice services on 5/12/24. ~ The facility completed Quarterly MDS assessments for R12 on 5/24/24 and 8/24/24. On 9/10/24 at 11:13 AM, Surveyor interviewed Registered Nurse (RN)-E who completed the facility's MDS assessments. RN-E confirmed a Significant Change MDS assessment should have been completed when R12 discharged from Hospice services. RN-E indicated RN-E was able to see that R12 discharged from Hospice services on R12's medical record dashboard and also indicated R12's discharge from…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 staff and resident interview and record review, the facility did not ensure 1 resident (R) (R11) of 1 resident received the necessary care and services to prevent and monitor weight loss or gain. Staff did not notify R11's physician of a significant weight gain and did not follow the physician's order for weight monitoring. Findings include: The facility's Weight Monitoring policy, dated 12/21/22, indicates: The Interdisciplinary Team (IDT) will strive to prevent, monitor, and intervene for undesirable weight changes for residents .1. The nursing staff will measure a resident's weight on admission, the next 2 days, and weekly for 3 additional weeks thereafter .3. Weights will be recorded in the resident's electronic health record .6. Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation .8. The threshold for significant weight change will be based on the following criteria, a. 1 month - 5% weight change is significant; greater than 5% is severe; b. 3…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-11 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not monitor for adverse reactions of a high-risk medication for 1 resident (R) (R20) of 5 residents reviewed for unnecessary medications. R20 was prescribed lamotrigine (an anticonvulsant medication). The facility did not monitor for adverse reactions or side effects of the high-risk medication. Findings include: Per medlineplus.gov, potential side effects for lamotrigrine include: loss of balance or coordination, double vision, blurred vision, uncontrollable movements of the eyes, difficulty thinking or concentrating, difficulty speaking, headache, drowsiness, dizziness, diarrhea, constipation, loss of appetite, weight loss, nausea, vomiting, and uncontrollable shaking of a part of the body. Some side effects can be serious such as swelling of the face, throat, tongue, lips, and eyes, difficulty swallowing or breathing, hoarseness, seizures, stiff neck, sensitivity to light, unusual bleeding or bruising, rash, swollen lymph nodes, yellowing 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 residents (R) (R11 and R24) of 5 sampled residents were monitored for adverse consequences of an antipsychotic medication. R11 was prescribed aripiprazole (an antipsychotic medication) for schizoaffective disorder. The facility did not complete an Abnormal Involuntary Movement Scale (AIMS) (a rating scale that helps identify and monitor side effects of antipsychotic medications) when R11 admitted to the facility on antipsychotic medication. R24 was prescribed lithium carbonate (an antipsychotic medication) for bipolar disorder. The facility did not complete an AIMS or implement monitoring for adverse reactions to the antipsychotic medication. Findings include: The facility's Psychotropic Medications policy, dated 10/24/22, indicates: Residents should not receive psychotropic drugs unless the medication is necessary to treat specific conditions as diagnosed and documented in the clinical record and the medication is beneficial to 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · Dcited before2024-09-11 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 3 errors occurred during 25 opportunities which resulted in a 12% medication error rate that affected 1 resident (R) (R14) of 4 residents observed during medication administration. On 9/9/24, R14 was administered three medications in the wrong form per the manufacturer's instructions. Findings include: The facility's Medication Administration policy, revised January 2024, indicates: If it is safe to do so, medication tablets may be crushed or capsules emptied using the following guidelines and with a specific order from the prescriber: Long acting, extended release, or enteric coated dosage forms should generally not be crushed; an alternative should be sought. On 9/9/24, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] with diagnoses including cancer, hypertension, chronic kidney disease,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-11 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 1 resident (R) (R13) of 5 sampled residents was offered a pneumococcal vaccine. R13's medical record did not contain documentation that R13 was offered a pneumococcal vaccine. Findings include: The facility's Pneumococcal Vaccine (Series) policy, dated 1/11/24, indicates: It is the policy of the facility to offer residents immunization against pneumococcal disease in accordance with current Centers for Disease Control and Prevention (CDC) guidelines and recommendations .1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented including efforts to determine date of immunization or type of vaccine received .2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized .4. The resident/representative retains the right to refuse 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-08 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure an allegation of abuse was reported to Nursing Home Administrator (NHA)-A and the State Agency (SA) for 2 residents (R1 and R2) of 4 sampled residents. On 5/23/24, R1 entered R2's room, threw a Styrofoam cup full of coffee creamers at R2, and verbally threatened R2. Staff did not report the allegation of abuse to NHA-A and the facility did not report the allegation of abuse to the SA. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, states the facility will report all alleged violations to the Administrator, State Agency, Adult Protective Services and all other required agencies (e.g., law enforcement when applicable) within a specified timeframe: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-08 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond 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 staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 2 residents (R) (R1 and R2) of 4 sampled residents. On 5/23/24, R1 entered R2's room and threw a Styrofoam cup full of creamers at R2. The incident was not thoroughly investigated to ensure further abuse was prevented and resulted in another allegation of abuse involving R1 and R2 on 5/24/24. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, states the facility will initiate an investigation for allegations or suspicions of abuse, including: 1. Identify staff responsible for the investigation; 2. Exercise caution in handling evidence that could be used in a criminal investigation (e.g., not destroying evidence); 3. Investigate different types of alleged violations; 4. Identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s); 5. Focus 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-08 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure physician visits were completed timely for 2 residents (R) (R2 and R4) of 5 sampled residents. R2 was admitted to the facility on [DATE]. R2 was not seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. R4 was admitted to the facility on [DATE]. R4 was not seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Findings include: The facility's Leadership Policies and Procedures indicates: VI: Medical Services: .2. The physician visits the patient/resident according to the following guidelines: Every months for three months and every 60 days thereafter, or more often as clinically driven. 1. On 7/8/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including large cell lymphoma, lymphedema, and encounter for palliative care. R2's Minimum Data…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-20 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure laboratory services were provided timely for 1 Resident (R) R2) of 5 sampled residents. The facility did not have a process in place to audit for expired lab supplies which caused a delay in obtaining a Respiratory Panel for R2. Findings include: On [DATE], Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and cerebral infarction (also known as stroke). R2's Minimum Data Set (MDS) assessment, dated [DATE], contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R2 had little cognitive impairment. R2 was responsible for R2's healthcare decisions. In a note entered at 3:45 AM on [DATE], R2's medical record indicated R2's Nurse Practitioner (NP) ordered a Respiratory Panel for symptoms of upper respiratory illness. A nursing…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-07-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 26 residents residing in the facility. The facility did not consistently monitor and document warewasher (dishwasher) wash and rinse cycles. Findings include: During an initial tour of the kitchen beginning on 7/10/23 at 8:30 AM, Dietary Manager (DM)-D indicated the facility followed the Wisconsin Food Code. DM-D confirmed the facility's dishwashing machine was a single tank, conveyor, dual temperature machine and indicated the wash cycle temperature should reach at least 160 degrees Fahrenheit (F) and the rinse cycle temperature should reach at least 180 degrees F. The Wisconsin Food Code 2022 documents at 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than .(3) For a single tank, conveyor, dual temperature machine, 71 Celsius/160 Fahrenheit. The facility's Dish…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-07-12 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infection. The facility did not implement a water management plan that identifies all areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This had the potential to affect all 26 residents in the facility. The facility did not identify where Legionella and other opportunistic waterborne pathogens can grow and spread. The facility did not document flushing or other measures to prevent the growth of opportunistic waterborne pathogens such as Legionella in identified areas where such pathogens may grow. Findings include: The facility's Legionella Surveillance Policy, dated 10/24/22, contained the following information: It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections .Physical Controls: i. Cooling towers 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff and resident interview, and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being in accordance with the comprehensive plan of care for 1 Resident (R) (R11) of 1 resident. The facility did not apply R11's Tubigrips (compression stockings) per R11's physician order and plan of care. Findings include: The facility's Comprehensive Care Plan policy, revised 9/23/22, contained the following information: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. On 7/10/23 Surveyor reviewed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure neurological checks were completed per policy after a fall for 1 Resident (R) (R21) of 4 residents reviewed for falls. Staff did not consistently complete neurological checks after R21 fell on 7/1/23. Findings include: The National Library of Medicine (https://www.ncbi.nlm.nih.gov/) states, The neurological examination in the setting of trauma is a systematic evaluation of important clinical signs that provide evidence to help determine further management and investigation of the patient's condition .In the setting of trauma, a neurologic examination is focused on identifying and assessing the functions of vital portions of the central nervous system. The facility's Fall Prevention and Management Guidelines, revised 11/8/22, contained the following information: When a resident experiences a fall, the facility will: Complete a post-fall assessment and review: Physical assessment with vitals signs. Neurochecks for any unwitnessed fall or…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-12 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 29 opportunities which resulted in a 6.9% medication error rate that affected 2 Residents (R) (R21 and R2) of 11 residents observed during medication pass. Licensed Practical Nurse (LPN)-H administered insulin lispro (rapid acting insulin) to R21 forty seven minutes before dinner was scheduled to be served. In addition, LPN-H did not prime the insulin pen with 2 units of insulin prior to administration. LPN-H administered insulin aspart (rapid acting insulin) to R2 sixty four minutes before dinner was scheduled to be served. Findings include: The facility's Medication Administration Subcutaneous Insulin policy contained the following information: To administer subcutaneous insulin as ordered and in a safe, accurate and effective manner .Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

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 →

RatingThis homeChain avg
Overall 4 of 52.7+1.3 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 3 of 53.4-0.4 vs chain
Quality measures 2 of 52.5-0.5 vs chain
The other 58 homes this chain runs (chain average 2.7★, per CMS)
1 of 5Elroy Health ServicesElroy, WI 1 of 5Florence Health ServicesFlorence, WI 1 of 5Hopkins Restorative Care CenterHopkins, MN 1 of 5La Crescent Health ServicesLa Crescent, MN 1 of 5Little Chute Health ServicesLittle Chute, WI 1 of 5Minot Health And Rehab, LLCMinot, ND 1 of 5Plymouth Health ServicesPlymouth, WI 1 of 5Rochester Restorative Care CenterRochester, MN 1 of 5Sheboygan Progressive Health ServicesSheboygan, WI 1 of 5Williams Bay Health ServicesWilliams Bay, WI 1 of 5Wisconsin Rapids Health ServicesWisconsin Rapids, WI 2 of 5Birch Hill Health ServicesShawano, WI 2 of 5Colonial Health ServicesColby, WI 2 of 5Evergreen Health ServicesShawano, WI 2 of 5Green Bay Health ServicesGreen Bay, WI 2 of 5Heritage Health ServicesPort Washington, WI 2 of 5Lake Country Health ServicesOconomowoc, WI 2 of 5Lancaster Health ServicesLancaster, WI 2 of 5Maple Ridge Health ServicesMilwaukee, WI 2 of 5Menomonee Falls Health ServicesMenomonee Falls, WI 2 of 5Mineral Point Health ServicesMineral Point, WI 2 of 5Soldiers Grove Health ServicesSoldiers Grove, WI 2 of 5Stevens Point Health ServicesStevens Point, WI 2 of 5Sunrise Health ServicesMilwaukee, WI 2 of 5Three Oaks Health ServicesMarshfield, WI 2 of 5Tomahawk Health ServicesTomahawk, WI 2 of 5Whitewater Health ServicesSt Charles, MN 2 of 5Willowcrest Health ServicesSouth Milwaukee, WI 3 of 5Cedarburg Health ServicesCedarburg, WI 3 of 5Court Manor Health ServicesAshland, WI 3 of 5Hayward Health ServicesHayward, WI 3 of 5Homestead Health ServicesNew Holstein, WI 3 of 5Mercy Health ServicesMilwaukee, WI 3 of 5Morningside Health ServicesSheboygan, WI 3 of 5Oakwood Health ServicesAltoona, WI 3 of 5Randolph Health ServicesRandolph, WI 3 of 5Rib Lake Health ServicesRib Lake, WI 3 of 5River's Bend Health ServicesManitowoc, WI 3 of 5Riverview Health ServicesTomahawk, WI 3 of 5Sheboygan Health ServicesSheboygan, WI

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 / managerTypeRoleShareSince
NSHR OPERATIONS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/01/2019
ARROWHEAD 123 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 10/01/2019
THE LANE MORRELL BOWEN TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF10%since 10/01/2019
MILLS, DAVIDIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST18%since 10/01/2019
CIBC BANK USAOrganization5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 12/31/2024
BAUMANN, TROYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2019
HOEHN, JEFFREYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2019
CLIFTONLARSONALLEN LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/23/2025
CONTINUUM THERAPY PARTNERS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
NORTH SHORE HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/23/2025
NSH REHAB LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
WIPFLI LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2025
BELONGIA, CHRISTINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2019
GEE, DARRENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/30/2021
GREER, LAURENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/29/2023
HLINAK, KATIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/10/2026
PATZER, COLLEENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/14/2023
PURTELL, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2019
RAMNANAN, KESHNIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2023
NSH 1 HAMILTON DRIVE LLCOrganizationADP OF THE SNFsince 12/01/2019

CMS files one row per role, so the 40 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.

10 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.

$3.9M
Net patient revenuemost recent cost report
-0.1%
Operating marginrevenue minus expenses
$199K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 32%Medicare 8%Other / private 60%

This home reported $199K 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

$365per resident / day
operating cost
$11,098per month
≈ monthly operating cost
$365per day
avg. revenue, all payers

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

What families pay in WI

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525664. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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