Waunakee Valley Senior Living

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

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.

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.

64.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 115 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 78.3% 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 83 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 84 beds and averages 54.3 residents a day — about 65% 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 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 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 3.32 hrs/resident/day on weekends vs 3.77 on weekdays — 12% thinner on weekends. RN hours go from 0.60 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are unchanged from the previous inspection. 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.

24 citations, most serious first. The 14 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-11-11 · 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 record review and interviews, the facility did not ensure each resident received adequate supervision to prevent accidents from elopements for 1 of 3 residents (R4) reviewed for accidents. R4 was identified as a risk for wandering and has a Wanderguard attached to her walker. R4 eloped from the facility on 10/26/24 and the Wanderguard alarm system did not activate. The facility did not know R4 had left the building until local law enforcement contacted the facility. R4 traveled four (4) blocks and crossed a busy intersection. The facility's failure to provide adequate supervision created a reasonable likelihood for serious injury or harm leading to a finding of immediate jeopardy that began on 10/26/24. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on 10/30/24 at 12:54 PM. The immediate jeopardy was removed on 10/27/24 and corrected on 10/30/24. This is being cited as past noncompliance. Findings: The facility policy, Guideline for Elopement/Missing Resident, dated 12/31/23,…

  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 · Past Non-Compliance
• Immediate jeopardy · J2024-08-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure each resident receives cares, consistent with professional standards of practice to prevent pressure injuries (PIs) for 2 of 2 residents (R) sampled out of a total sample of 13 (R4 and R6). R4 was admitted on [DATE], without a pressure injury or catheter. Resident was hospitalized on [DATE], returning on [DATE] with a foley catheter in place. The facility failed to ensure interventions to prevent medical device-related pressure injuries were implemented correctly to prevent PI development, failed to complete weekly measurements and assessments, and failed to complete treatments as ordered. R4 subsequently developed a full thickness wound that extended from the tip of the penis where the catheter is placed, through the meatus, and down to the shaft. These failures created a finding of immediate Jeopardy (IJ) which began on [DATE]. The NHA (Nursing Home Administrator) was notified of the IJ on [DATE] at 1:20 PM. The jeopardy was…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-04-09 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 of 2 (R52) sampled residents.R52 had a diagnosis of CHF (Congestive Heart Failure). The facility failed to complete comprehensive assessments for R52 including daily weights, failed to consult the physician regarding R52's weight gain resulting in R52 having a change in condition requiring hospitalization for exacerbation of his CHF.Evidenced by:According to an article from The National Library of Medicine titled Congestive Heart Failure (Nursing) last updated 11/5/23, .Monitoring: Patients with HF require frequent monitoring of vital signs, including oxygen saturation .Frequent assessment and monitoring for symptoms is also indicated. All patients with HF require daily weight monitoring . Congestive Heart Failure (Nursing) - StatPearls - NCBI Bookshelf (nih.gov)According to the American Heart…

  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
• Actual harm · G2026-04-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not provide the necessary respiratory care and services 1 of 1 (R52) sampled residents.R52 had orders to use Bilevel Positive Airway Pressure (BIPAP), BIPAP settings were not transcribed, and the facility did not ensure staff had the right settings for usage, did not ensure it was being worn, and did not contact R52's physician after refusals to wear the BIPAP, no evidence of Risk. Vs benefits being provided regarding refusals resulting in R52 being sent to the hospital for exacerbation of acute respiratory failure with hypoxia (low oxygen levels in the body tissues) and hypercarbia (elevated levels of carbon dioxide in the blood).Evidenced by:R52 was admitted to the facility from the hospital on 9/10/25 and has diagnoses that include congestive heart failure, hypertension, obstructive sleep apnea (OSA), and respiratory failure.R52's most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 15,…

  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 · F2026-04-09 · 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 interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. This has the potential to affect the census of 59 residents.The facility does not have monthly Infection Control Rates documented accurately and does not have Infection Control Rates documented by infection type.This is evidenced by:The facility policy Infection Prevention and Control Program (IPCP), dated 11/19/25, includes: The campus has a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases that: a. Covers all residents, staff. c. Follows accepted national standards. The campus shall designate a member of the clinical team to monitor the campus IPCP program to perform surveillance to identify, investigate, control, and prevent the spread of infection and reporting for the IPCP. b. Surveillance activities to identify, investigate, control,…

  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 · D2026-04-09 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 sampled residents (R10) reviewed for self- administration of medications. R10 was observed to have 3 cups of medications left on their bedside table for them to take independently. R10 does not have an assessment for self-administration of medications indicating that they are safe to administer medications independently. Evidenced by:The facility's policy titled Guidelines for Self-Administration of Medications last reviewed on 12/16/25 states in part .Procedure 1. Residents requesting to self-medicate or has self-medication as a part of their plan of care shall be assessed using the observation [Facility's Corporation Name]- Self Administration of Medication withing the electronic health record. Results of the assessment will be presented to the physician for evaluation and order for self-medication. R10 was admitted to the facility on [DATE] with…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-09 · 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, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 1 resident reviewed (R8) for smoking. R8 began smoking at the facility and the facility was not able to provide documentation indicating that R8 was assessed to be a safe, independent smoker, once the facility was made aware. Evidenced by:The facility's policy titled Smoke Free Environment last reviewed on 11/20/25 does not address steps taken if a resident starts smoking once they are admitted to the facility. R8 was admitted to the facility on [DATE] with diagnoses that include malignant neoplasm of overlapping sites of right breast (breast cancer), secondary malignant neoplasm of bone (bone cancer), major depressive disorder, and bipolar disorder. R8's most recent MDS (Minimum Data Set) dated 4/2/26 states that R8 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R8 is cognitively intact. It is important to note that despite…

  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 · D2025-01-23 · tag F0645 — isolated
  PASARR screening for Mental disorders or Intellectual Disabilities
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not follow through with the appropriate steps of the Preadmission Screening and Resident Review (PASRR) process for 1 of 5 residents (R48) reviewed. R48 did not have a PASRR level II completed. This is evidenced by: Per the facility, they do not have a PASRR Policy and Procedure, but they follow the Wisconsin PASRR QRG (Quick Reference Guide) process. Surveyor was also given the Forward Health Update dated November 2023 that the facility references. The Wisconsin PASRR QRG documents the following in verbiage and a flow diagram: What is a PASRR: Preadmission Screening and Resident Review (PASRR) is a federal requirement established to identify individuals with mental illness and/or intellectual developmental disability to ensure appropriate placement in the community or a nursing facility. Purpose: The purpose of a Level I screen is to identify individuals whose total needs require that they receive additional services for their intellectual disabilities or serious mental illness. Who Requires a PASRR: All residents admitting to…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-23 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice when experiencing a change in condition for 2 of 2 residents (R52 and R305) reviewed for quality of care. R52 and R305 has documented nursing assessments completed and signed by Licensed Practical Nurse (LPNs), which are required to be completed or signed off by a Registered Nurse (RN). Evidenced by: Surveyor requested a facility policy outlining RN assessments, facility staff stated they were unable to provide this policy. N9 Wisconsin Nurse Practice Act states, in part: N6.03 Standards of practice for registered nurses. An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-23 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide behavioral health services to ensure the highest practicable mental and psychosocial well-being for 1 of 2 residents (R11) reviewed. R11 admitted to the facility with a history of depression. The facility failed to offer R11 services related to this diagnosis even after R11's husband passed away in [DATE]. This is evidenced by: The National Institutes for Health states, in part: .Depression, even severe depression, can be treated. It's important to seek treatment as soon as you begin noticing signs . A doctor can rule out medical possibilities through a physical exam, learning about your health and personal history, and lab tests. If a doctor finds there is no medical condition that is causing the depression, he or she may suggest a psychological evaluation and refer you to a mental health professional . The State Operations Manual, Appendix PP states, in part: Providing behavioral health care and services is an integral part 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-23 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure 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 observation, interview, and record review, the facility did not ensure residents are free of significant medication errors for 1 of 1 out of 14 sampled residents (R52). R52 had an order for abiraterone (used to treat prostate cancer that has spread to other parts of the body) 1000 mg (milligrams) to be administered once a day by mouth. This medication has precise administration instructions, that it needs to be taken with a full glass of water and on an empty stomach. Residents are instructed not to eat anything for at least two hours before and one hour after taking this medication. This medication was administered late on 11/30/24 and 12/1/24. Evidenced by: The facility policy, titled, Medication Administration Times, dated 12/17/24, states, in part: . Purpose: To ensure medication is administered in resident centered fashion and documented in medical record. Procedures . Unless a specific times is designated by the attending physician medications shall be administered at the following times .…

  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 · D2025-01-23 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure 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 record review, the facility did not ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. This occurred for 1 of 3 medication carts observed. During the three-day survey, 1 of 3 medication carts was left unattended, unlocked, and out of view of staff. Evidenced by: The facility policy titled Medication Storage in the Facility revised 10/2019 states in part .B. Only licensed nursed, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access . On 1/21/25 at 9:18 AM, Surveyor observed the medication cart located on A wing to be sitting in the hallway unlocked. On 1/21/25 at 9:19 AM, Surveyor observed LPN J (Licensed Practical Nurse) exit another room on the hallway and approach the medication cart. Surveyor asked LPN J what the process is when they leave the medication cart, LPN J stated that they are to…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-11-11 · tag F0730 — pattern
  Observe each nurse aide's job performance and give regular training.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not ensure Certified Nursing Assistant (CNA) staff received a performance review at least every 12 months for 5 of 5 staff members selected for review. CNA T was hired on 3/1/23 and has not had an evaluation in the past 12 months. CNA U was hired on 3/1/23 and has not had an evaluation in the past 12 months. CNA S was hired on 3/1/23 and has not had an evaluation in the past 12 months. CNA R was hired on 3/1/23 and has not had an evaluation in the past 12 months. CNA H was hired on 8/17/23 and has not had an evaluation in the past 12 months. Evidenced by: The facility does not have a Policy and Procedure in place for CNA performance evaluations. Example 1 CNA T was hired on 3/1/23 and has not had an evaluation in the past 12 months. CNA T was due for an evaluation on or around 3/1/24. Example 2 CNA U was hired on 3/1/23 and has not had an evaluation in the past 12 months. CNA U was due for an evaluation on or around 3/1/24. Example 3 CNA S was hired on 3/1/23 and has not had an evaluation in the past 12 months. CNA S was due 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-11-11 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation, interview, and record review, the facility did not ensure that all residents receive food at a palatable temperature for 1 of 1 test trays. A test tray was found to outside of acceptable temperature range and not palatable. Evidenced by: The facility policy, Food Production Guidelines, dated 1/24, states, in part; .Procedures 5. Food is served as soon after preparation as possible and is held at the following temperature: Hold food- HOT= 135F or above. Hold food- COLD= 41F or below . On 10/28/24 at 1:20 PM, Surveyor requested to temp the last tray on the meal cart. Meat and noodles temped at 123.8°F, corn temped at 125.8°F and milk 41.7°F. The meat was difficult to chew, and meat and noodles were cold. The corn was cold and milk was warm. On 10/28/24 at 1:30 PM, Director of Food Services J indicated hot foods should be served hot and cold foods served cold. Director of Food Services J indicated understanding on the concern with the temperatures of the food on the meal tray.

  Nutrition and Dietary 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.

Fines & penalties

$32,856 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $16,055 — penalty dated 2024-11-11
• $16,801 — penalty dated 2024-08-06
• Medicare payment denial — starting 2024-09-04 for 44 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.

Part of a chain

This home belongs to TRILOGY HEALTH SERVICES — 123 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 22 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.

8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $906K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

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

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