Vernon Manor
310 Fairlane Dr, Viroqua, WI 54665 · Government - County · 80 certified beds · (608) 637-5400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $12,649 in federal fines (most recent 2023-08-28)
- its payroll-based staffing score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.0% | 16.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 0.7% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.2% | 2.1% | 0.9% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 4.5% | 2.7% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 5.7% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.5% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 28.6% | 18.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.8% | 16.9% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.3% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.0% | 5.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.6% | 24.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.3% | 15.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.6% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 78.0% | 82.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 11.4% | 23.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.4% | 15.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.26 | 1.66 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 4.48 | 2.29 | 1.80 | 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.
52.3% 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 51 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 76.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 34 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 28% 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
| 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 | 52.3%CMS range 43.0–63.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.1–14.1 | 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 | 76.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 61.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 52.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 7.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.4%CMS range 3.0–12.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 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 80 beds and averages 49.9 residents a day — about 62% occupied, or roughly 30 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 4.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.96 is at or above 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 4.23 hrs/resident/day on weekends vs 4.74 on weekdays — 11% thinner on weekends. RN hours go from 0.97 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Immediate jeopardy · J2023-08-28 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 were free from significant medication errors for 2 of 2 sampled residents (R65 and R265) reviewed for medication errors. R65 had an order to receive 12.5 mcg (micrograms) of levothyroxine. The medication was transcribed into the facility's Electronic Health Record (EHR) as 125mcg. R65 received 45 doses in 46 days of the incorrect dose of levothyroxine. R65 died in the hospital as a result of the medication error which caused Thyrotoxicosis. The facility's failure to ensure that residents were free from a significant medication error created a finding of immediate jeopardy that began on [DATE]. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on [DATE] at 3:00 PM. The immediate jeopardy was removed [DATE]; however, the deficient practice continues at a scope/severity level of D as the facility continues to implement its action plan and as evidenced by: R265 did not receive the correct dosage of pain medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-02-27 · tag F0887 — widespreadEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on document review, interview and policy review, facility failed to ensure that when COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized for 4 of 4 staff reviewed. This has the potential to affect all 46 residents residing within the facility.Facility failed to have documentation of staff COVID-19 vaccination status, that staff were educated about the COVID-19 vaccine, the COVID-19 vaccine was offered and signed consents of accepting the vaccine or declining the vaccine for the following four staff Director of Nursing (DON), Licensed Practical Nurse (LPN)1, Resident Care Assistant (RCA)1 and Certified Nurse Aide (CNA)1 Findings include:Review of the facility's policy titled COVID-19 Vaccinations dated 07/03/2025 revealed, 1. It is the policy of this facility, in collaboration with the medical director, to have an immunization program against infectious diseases in accordance with national standards 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 · E2026-02-27 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to document and respond to residents' grievance regarding removal of their bedrails for five of five residents (R6, R8, R23, R26 and R42). R6, R8, R23, R26 and R42 voiced grievances regarding their bedrails, and the facility did not follow their grievance policy. Findings include: Reviewed facility's undated policy titled, Grievance indicated, Facility will make prompt efforts to resolve grievances a resident may have. The intent of the grievance process is to support each resident's right to voice grievances (e.g., those about treatment, care, management of funds, lost clothing, or violation of rights) and to assure that after receiving a complaint/grievance, the facility actively seeks a resolution and keeps the resident appropriately apprised of its progress toward resolution. 1.Review of R26's admission Record, located in the EMR (electronic medical record) under the Profile tab revealed the resident was admitted 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.
- Potential for harm · Dcited before2026-02-27 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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, record review, and policy review, the facility failed to ensure one of two residents (R43) reviewed for advanced directives had a valid advanced directive in place. R43's Physician's Orders Scope of Treatment (POST) form had not been signed by the Guardian when R43's code status was changed from Full Code to Do Not Resuscitate (DNR). Findings include:Review of the facility's policy titled, Advance Directive, dated 08/2017 revealed, [Facility name] will encourage residents to exercise their right to formulate an advance directive at their option. Staff will inform and educate resident of their rights to accept or refuse medical treatments, refuse to participate in experimental research and to formulate an advanced directive to express their health care wishes .Upon admission, identify if the resident has an advanced directive and if not, determine if the resident wishes to formulate an advanced directives . Examples include a pre-existing medical order for do not resuscitate.POST, or other…
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 · D2026-02-27 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and policy review, the facility failed to ensure 2 of 3 Residents (R58 and R59) reviewed for beneficiary notices received the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) of Non-Coverage forms when skilled therapy was being discontinued.This failure did not allow residents/responsible parties to decide whether to receive the care that might not be paid for by Medicare if they chose to assume financial responsibility for R58 and R59.Findings include:Review of the Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) Form CMS-10055, dated 2020, provided by the facility, and served as the facility's policy for completion of the SNF ABN revealed, Medicare requires SNFs to issue the SNF ABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: not medically reasonable and necessary; or is considered custodial. SNF ABN provides information to the beneficiary so 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.
- Potential for harm · Dcited before2026-02-27 · 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, record review, and policy review, the facility failed to ensure all incidents and/or allegations of abuse were reported immediately but no later than two hours to the State Survey Agency (SSA) for two of three residents (R55 and R43) reviewed for abuse.Allegations were made that R9 hit R43 on 05/03/25 and R9 hit R55 on 05/08/25; these instances were reported to the State Agency more than eight months later on 02/19/26. Findings include:Review of the Vulnerable Adult' policy dated 11/03/25 and provided by the facility read, All residents have the right to be free from neglect, verbal, sexual, and mental abuse . Residents must not be subjected to abuse by anyone, including but not limited to: facility staff, other residents . Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish . All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, 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 · D2026-02-27 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review, the facility failed to ensure one of one medication storage room was free of expired COVID-19 tests.This practice fails to ensure that biologicals stored in the medication storage room efficacy is maintained.Findings include:Review of the facility's policy titled Medication Administration Policy reviewed 02/2019, revealed under procedure, 3.Check that medication are labeled with open date and not expired before administrating.On 02/26/26 at 10:54 AM, Surveyor observed the only medication storage room with the facility's Infection Preventionist (IP). Surveyors' observation revealed three of three boxes of iHealth COVID -19 Antigen Rapid Test with expiration dates of 09/02/25. The IP confirmed at this time that the tests were expired. Observation revealed one box of COVID-19 tests was opened and three tests had been used. The IP stated three test from the expired boxed were used the previous day. During an interview on 02/26/2026 at 10:56 AM, the IP stated it was her expectation there would not have been any expired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-19 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure residents (R) were free from physical abuse for 1 (R22) of 3 residents reviewed for abuse out of 18 sample residents. R15 threw a metal spoon and hit R22 on the back of the head during an activity. Findings include: Review of R15's ''admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnosis including unspecified dementia. Review of R15's significant change ''Minimum Data Set (MDS)'' with an assessment reference date (ARD) of 07/07/24 located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of two out of 15 which indicated the resident was severely cognitively impaired. Further review revealed R15 exhibited physical and verbal behaviors towards others. Review of R15's Care Plan, located under the ''Care Plan'' tab of the EMR and dated 08/26/24, revealed a care plan related to altered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-19 · 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 record review, document review, interviews, and policy review, the facility failed to timely report an allegation of verbal abuse to the State Agency (SA) for 1 of 3 residents (R33) reviewed for abuse out of a total sample of 18 residents. Findings include: Review of the facility's Grievance Log for September 2024 revealed a grievance dated 09/17/24 that indicated R33 reported that Certified Nurse Aide 5 (CNA) had verbally abused her. Review of R33's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, heart failure, and chronic obstructive pulmonary disease (COPD). Review of the EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/24 under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of the facility's investigative file revealed that CNA6…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-19 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to thoroughly investigate an incident of resident-to-resident abuse for 1 of 3 residents (R22) reviewed for abuse out of 18 sample residents. Findings include: Review of R15's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed R15 admitted to the facility on [DATE] with diagnoses of unspecified dementia, anxiety disorder and depression. Review of R15's significant change ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 07/07/24, revealed a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated severe cognitive impairment. Further review revealed R15 exhibited physical and verbal behaviors towards others. Review of R22's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed R22 admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Review of R22's quarterly ''MDS'' with an ARD (Assessment Reference Date) of 09/04/24 revealed a BIMS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the facility failed to develop a person-centered care plan to include pertinent diagnoses and care areas for 2 residents (R28 and R59) of 18 sampled residents. Findings include: Review of R28's Admitting and Discharge Record located in the electronic medical record (EMR) under the Face Sheet tab, revealed an admission date of 08/29/24 with diagnosis of malignant carcinoid tumor of the ileum. Review of R28's admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 09/04/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R28 was cognitively intact. Review of the Care Area Assessments (CAAs) revealed urinary incontinence, psychotropic drug use, and pain were triggered by the MDS and had a checkmark for Addressed in Care Plan. Review of R28's EMR under the Care Plan tab revealed no mention of pain, incontinence, and psychotropic drug use in the Care Plan. Review of R28's Guidelines for Daily Care, located in R28's room revealed…
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 6 citations
- Potential for harm · F2024-07-31 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections such as COVID-19. This had the potential to affect all residents residing within the facility at the time of the outbreak on 7/25/24. As of 7/25/24, the facility was in a COVID-19 outbreak with 1 staff positive for COVID-19. - The facility line listings were not completed contemporaneously, and the line lists did not contain symptomology. - During the survey, staff were observed throughout the facility not wearing source control. - The facility did not track community transmission rates and hospital admissions. - The facility did not recognize the outbreak and did not implement their COVID-19 procedures. - The facility did not recognize or ensure they screen all residents for signs and symptoms of COVID-19 once the outbreak was identified. - The facility did not ensure staff who were positive for COVID-19 did not work. - The facility did not test…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-31 · 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 implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 of 3 reportable incidents involving (R1 and R2) On 3/19/24, R2 had a physical altercation with another resident (R1). This allegation of abuse was not reported to local law enforcement. Evidenced by: The facility policy titled, Resident Abuse: Investigating and Reporting Allegations of abuse, neglect, mistreatment, injuries of unknown source, misappropriation of resident property and resident to resident altercations, last reviewed 1/15/24, states in part . Policy: [Facility Name] believes all resident have the right to be free from abuse including mental, verbal, and sexual; neglect, maltreatment, exploitation, corporal punishment, involuntary seclusion, and misappropriation of property. The policy of [Facility Name] is to immediately investigate and report any suspicious event of the above nature.…
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 before2023-08-28 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents advance directive was signed by resident or resident representative for 4 of 17 residents (R32, R54, R56, and R1) reviewed for code status of total sample of 24. The code status preference form for R32, R54, R56, and R1 is not signed by the resident or legal representative. Findings include The facility commonly uses a Provider Orders for Scope of Treatment (POST) form to distinguish resident code status. Under section E, the form states, Signature of Patient/Agent/Guardian (either patient/agent/guardian must sign or health care professional must initial). Additionally, the form states, Reviewing POST: The POST should be reviewed periodically and if: .The patient is transferred from one care setting or care level to another . The facility's advance directive policy states the following: *Upon admission, identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advance directive.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-28 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not provide privacy during personal care for 1 out of 17 residents (R214). R214's room door was left open, and the privacy curtain was not pulled during wound care to R214's coccyx. This is Evidenced by: The facility policy entitled, Resident Care, dated 10/2017, states, in part: . POLICY: It is [NAME] Manor's policy to provide resident care that promotes quality of care and quality of life. Procedure: . - . For most adults, washing is a personal and private activity and so it can be hard to adjust to this change. Always remember, it is important to be sensitive and tactful and to respect their dignity. - Personal cares can be difficult for care givers and is a common source of anxiety for many residents . - . residents may find it embarrassing to be undressed in the presence of other people. Keep them covered as much as possible during cares . R214 was admitted to the facility on [DATE] and has diagnoses that include Severe Protein-calorie…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-28 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not have evidence that all alleged violations are thoroughly investigated for 1 of 10 residents reviewed for abuse (R56). R56 alleged that money had been stolen from him and the facility did conduct a thorough investigation that includes interviews of other residents and monitoring of R56 as he made threats because of the alleged theft. Findings include: The facility's Resident Abuse policy states the following: *Misappropriation of resident property is defined as: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money without resident's consent. *The investigation will include interviewing alleged victim(s) and witnesses. Interviewing other residents to determine if they have been abused .other protection steps to consider: 15-minute checks, assess for the appropriateness of a room change, evaluate medical condition, psychological evaluation, behavior intervention changes. R56 is his own person…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure a resident with a catheter receives appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (R43) reviewed for catheter care. Staff did not perform appropriate hand hygiene while providing catheter care. There was no barrier placed under supplies on the bedside table during the catheter care. Staff placed dirty wash cloths directly on bedside table and did not disinfect bedside table after use. This is evidenced by: The facility policy, entitled Incontinent/Perineal Care, dated 5/7/21, states, in part: . Policy: .It is the policy of [NAME] Manor that perineal care will be provided to residents requiring assistance with bathing . Procedure: . The perineal area also is a primary portal of entry for bacteria into the urinary tract, potentially causing infection. Therefore, it is important that this area be kept as clean as possible. Incontinent care will be completed as follows: . -Wash hands or use…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$12,649 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $12,649 — penalty dated 2023-08-28
- Medicare payment denial — starting 2023-09-16 for 26 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| COUNTY OF VERNON | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 02/29/2008 |
| HENRY, MARY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 01/06/2025 |
| KILMER, BRUCE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 01/04/2025 |
| WALLESER, KEVIN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 01/04/2025 |
| GOCHANOUR, KIMBERLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/12/2024 |
| LANCASTER, REBECCA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/02/2024 |
| SPITZER, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/02/2024 |
| WHITE, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/02/2024 |
| WOODY, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/02/2024 |
CMS files one row per role, so the 25 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525562. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-27, 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.