Wood Aven Health and Rehabilitation
1821 N 4th Ave, Wausau, WI 54401 · For profit - Limited Liability company · 82 certified beds · (715) 675-9451 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (60%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 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 | 14.9% | 16.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.0% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.7% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 4.3% | 2.7% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 6.1% | 5.7% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.4% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 2.5% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 25.8% | 18.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 7.4% | 16.9% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 5.0% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 26.6% | 24.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.9% | 15.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.6% | 82.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.7% | 23.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 14.5% | 15.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.20 | 1.66 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.61 | 2.29 | 1.80 | better |
‡ 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.
66.1% 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 147 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 72 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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 | 66.1%CMS range 60.0–73.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 7.3–13.8 | 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 | 54.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 55.6% | 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 | 61.1% | 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 | 97.6% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.4% | 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 | 0.0% | 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 | 4.9%CMS range 2.5–9.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.69 | 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 82 beds and averages 71.3 residents a day — about 87% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.90 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.16 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 3.29 hrs/resident/day on weekends vs 4.15 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.31 to 0.78 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
- Actual harm · G2025-01-08 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that a resident (R) received treatment and care in accordance with professional standards of practice for 1 out of 18 residents sampled. (R321) R321 has a history of daily opiate use and constipation. The facility bowel protocol was not followed or a thorough GI assessment completed, causing actual harm to R321. R321 was hospitalized with severe pain and was admitted with a fecal impaction. Findings include: The facility's bowel protocol, reviewed on 11/18/24, includes, in part: Bowel and Bladder Management . Bowel: Constipation (If no bowel movement in > 48 hours; Perform steps sequentially) -Perform rectal check to determine if impaction is present - Encourage 2,000 ml daily fluid intake unless contraindicated -Consult Dietician for dietary recommendations -Sennoside 8.6 mg take 2 tablets by mouth at evening prn for 3 days -Bisacodyl suppository 10 mg per rectum daily prn for 3 days - Reattempt Sennoside or Bisacodyl if no results after 24 hours…
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 · D2026-05-27 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents were free from unnecessary medications for 1 of 3 residents (R) reviewed for medication errors (R2). R2 received Metformin (a medication to treat diabetes) for 8 days. R2 does not have a diagnosis of diabetes.Findings: R2 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia and chronic kidney disease. R2 has a Brief Interview for Mental Status (BIMS) score of 7/15 which means severe cognitive impairment. R2 has a legal representative for health care decision making. R2's care plan, last revised 01/26/2025, with a target date of 01/27/2026, states: At risk for impaired cognitive function/dementia or impaired thought process. Interventions include.review medications and record causes of cognitive deficit: new medications. R2's record review indicated the following:- Physician order dated 10/29/2024 to check R2's HgbA1c level (a blood test that measures an average blood sugar level over the past 2-3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-01 · tag F0628 — patternProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 4 of 5 residents (R1, R8, R19, and R67) or their representatives received the proper notice of transfer, reason for transfer, and ombudsman notification.-Facility did not have a specific reason for the transfer notice for R1, R8, R19, and R67.-Facility did not notify the ombudsman of R8, R19, and R67's transfers to the hospital.Findings include: Surveyor reviewed policy titled, Criteria for Transfer and Discharge, dated 12/25 last reviewed, .Procedure: 5. If the transfer or discharge is necessary for the resident's welfare and the residents' needs cannot be met in the Facility, the resident's physician shall document in the resident's medical record: a. The specific residents need that cannot be met . Surveyor reviewed policy titled, Transfer and Discharge (including AMA), dated 03/26, .3. The facility's transfer/discharge notice will be provided to the residents and residents representative in a language and way they can understand. The notice…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0554 — isolatedAllow 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 determine if self-administration of medications was clinically appropriate for 1 resident (R7) out of 3 residents reviewed for self-administration of medications in a sample of 17 residents. The facility did not ensure the interdisciplinary team (IDT) assessed and determined R7 was clinically appropriate to self-administer prescription topical creams and inhalers, located in R7's room and at bedside. This could result in an adverse event happening because of R7 incorrectly self-administering medications. Findings include:The facility policy, titled Self-Administration of Medications, last revised 03/2026, states, . a resident's cognitive, communication, visual, and physical ability to carry out this responsibility will be evaluated quarterly and as needed.if the resident is a candidate for self-administration of medications, this will be indicated in the medical record.resident's care plan will be updated to reflect self-administration.R7…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not notify the provider of changes in condition for 1 of 17 residents (R19) reviewed.This is evidenced by:The facility's Standing Orders, most recently reviewed and approved by the Medical Director on 03/05/26, states, Please follow these standing orders unless otherwise indicated by healthcare provider. Provider Notification: Systolic Blood Pressure less than 90 or greater than 200.R19 was admitted to the facility on [DATE] with diagnoses that include cognitive communication deficit, acquired absence of right leg above knee, chronic kidney disease stage 3.R19's most recent quarterly Minimum Data Set (MDS) assessment, dated 03/18/26, noted a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact.Surveyor reviewed R19's vital signs:*10/24/25, R19's blood pressure (BP) was documented as 83/50. No provider notification of systolic blood pressure (SBP) less than 90 was noted.*10/25/25, R19's BP was documented as 87/56. No provider…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 2 of 8 employees reviewed. -The facility did not ensure their abuse policy was implemented when two employees' Background Information Disclosures (BID) did not include results from the Department of Justice (DOJ) and Integrated Background Information System (IBIS) before Certified Nursing Assistant (CNA) P and Facility Driver O started working for the facility. Findings include:The facility's policy titled, Abuse Prevention reads in part, . Employee Screening . 2. All employees will be properly screened for criminal background.On 04/01/26 at 10:14 AM, Surveyor reviewed 8 random staff's BID.1. On 04/01/26 at 10:32 AM, Surveyor interviewed Regional Human Resource K and asked if facility had CNA P's DOJ and IBIS forms completed when facility ran CNA P's background on 11/01/24. Regional Human Resource reported that when the company took over last year, they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible for 1 out of 4 residents (R44).Staff transferred R44 with the incorrect mechanical lift resulting in a fall after Occupational Therapy (OT)'s recommendations for transfer were ordered. R44's care plan was not updated with transfer changes in a timely fashion.Findings include: Facility policy titled, Safe Resident Transfer Program, dated reviewed on 03/26, states: .Steps for Program use: #1. All transfers will be indicated in the care plan. 6. Staff always have the option of using higher level of transfer assist, if in their judgement, the residents condition warrants it; for example, a resident normally uses Ez-Stand but suddenly is unable to bear weight, then a full body lift should be used. Facility policy titled, Fall Prevention, dated reviewed on 11/24, states in part: .Procedure: A care plan is formulated based on the fall risk assessment. If a potential…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag 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 who is continent of bladder on admission receives services and assistance to maintain bladder function as possible for 1 of 5 residents (R54). The facility did not ensure an accurate bowel and bladder assessment completed upon admission to determine an appropriate toileting program or plan in place to manage current urinary status or regain/maintain urinary continence status. The facility policy titled Bowel and Bladder Assessment last revised 03/26 states: It is the policy of this facility to provide the resident who is incontinent of bowel and/or bladder the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. Under the section titled Purpose states: The purpose of the bowel and bladder evaluation is to develop an individualized, goal-oriented approach to elimination. Under the section titled Procedures states in part: 1. The Bowel and Bladder…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 who were fed by enteral means received the appropriate treatment and services to prevent complications for 2 of 2 residents (R10 and R55).The facility's policy and procedure included a method that is no longer recognized as a nationally accepted standard of practice. Staff were unable to provide a reference to a nationally recognized standard of practice used to develop their policy and procedure. Facility staff were observed using auscultation as it may not provide accurate results. R55 and R10's tube placement was checked using auscultation. This is evidenced by: Facility's policy titled, Gastrostomy Tube Care and Management, with a reviewed date of 03/2026, states in part: Policy: It is the policy of this facility to provide proper care and maintenance of gastrostomy tubes. Procedure: 4. Before every feeding, verify the tube position.check the position every shift and as needed using aspiration of gastric contents, air auscultation,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag 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 observation, interview and record review, the facility did not ensure that residents are free from significant medication errors for 1 of 17 residents (R55) R55 was not administered medication for bowel regimen based on physician orders. R55 was admitted to the facility on [DATE] with diagnoses of dysphagia, amyotrophic lateral sclerosis (ALS,) pneumonitis due to inhalation of food and vomit, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R55's physician orders dated 03/24/2026 state: Metamucil Oral Powder 48.57 % (Psyllium) Give 1 Tbsp via PEG-Tube one time a day for loose stools mixed in 4-8 ounces free water. R55's record shows last bowel movement was documented on 3/28/26 at 19:45 7:45 PM of incontinent small formed soft/normal stool. On 03/31/2026 at 8:41 AM, Surveyor observed Licensed Practical Nurse (LPN) D set up R55's medications which included order for Metamucil. LPN D measured 1 tablespoon of Metamucil and placed it into a 30cc medication cup 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 · Dcited before2026-04-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 3 of 17 sampled residents (R7, R43, and R31). Staff did not implement enhanced barrier precautions for R7 and R43. Staff did not perform hand hygiene during R31's medication administration.The facility policy, titled Enhanced Barrier Precautions, dated 03/24/2026, states, Initiation of Enhanced Barrier Precautions (EBP), the facility will have the discretion in using EBP for residents who do not have a chronic wound.an order for enhanced barrier precautions will be obtained for residents with any of the following: wounds (chronic wounds such as pressure ulcers.) even if a resident is not known to be infected or colonized with a methicillin drug resistant organism (MDRO).make gowns and gloves available immediately near or outside the resident's room. Example 1 R7 was admitted 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.
Show the remaining 6 citations
- Potential for harm · D2025-12-23 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review, the facility failed to administer medications as scheduled for one of two residents (Resident (R) 1) reviewed for pharmacy services out of a total sample of six residents. The failure to acquire and administer routine medications to R1 had the potential for unrelieved pain and adverse consequences.Findings include:Review of R1's undated admission Record located under the Profile tab in the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses of radiculopathy (a pinched nerve) and spinal stenosis (narrowing) in the cervical region (relating to the neck).Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/01/25, located under the MDS tab in the EMR revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R1 was cognitively intact.Record review of R1's undated Order Summary Report located under the Orders tab in the EMR 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.
- Potential for harm · D2025-03-26 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and policy review, the facility did not ensure allegations of mistreatment were thoroughly investigated for 1 of 1 (R3) resident reviewed. Certified Nursing Assistant (CNA) C made a comment about the way R3 smelled, allegedly stating R3 needed a bath because he smells like he came out of a barn. The facility investigation did not include all nursing staff working R3's rehabilitation unit during the time of the reported incident. This is evidenced by: The facility policy, Resident Rights-Abuse Prevention, which was not dated, included in part: Policy: It is the policy of this facility that each resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone . Procedures: Investigation-All identified events are reported to the Administrator/Designee immediately and will be thoroughly investigated. The investigation shall consist of: 5. An interview with staff members (on all shifts) having contact with the resident during the period of the alleged incident. 7. An interview with staff members (on all shifts) having contact with 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 · F2025-01-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility did not allow clean dishes sufficient time to air dry or store the clean dishes in a manner to prevent potential contamination. The facility practice has the potential to affect all 76 residents. This is evidenced by: The facility policy tilted Dishwashing and Ware Washing which was not dated was requested and received by Surveyor. The policy in part read: Objective: To ensure cleaning, sanitization and infection control in the dishwashing area to promote food safety, prevent contamination and minimize the risk of spreading infections. Washing (Mechanical or Manual): Dish Drying: ~Dishes, utensils and cookware will be allowed to air dry completely on clean, sanitized racks or drying shelves. Inverting Dishes: Inversion: All plates, bowls, cups and similar items will be inverted (placed upside down) during storage to prevent contamination from airborne particles and dust. On 1/07/25 at 9:55 AM, Surveyor observed Dietary Aide (DA) C doing dishes in the dish room. DA C was observed spraying dirty dishes and loading dishes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-08 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not effectively monitor psychotropic medications to ensure residents are receiving the lowest possible effective dose. The facility practice had the potential to affect 1 of 5 residents reviewed for unnecessary medications (R19). This is evidenced by: Surveyor requested and reviewed the facility policy titled Psychoactive Medications dated as most recently reviewed on 12/2024. The policy in part read: Policy: It is the policy of this facility to maintain every resident's right to be free from the use of psychoactive medication. ~Psychoactive medications .are to be administered only when required to treat the residents' medical symptoms. ~No psychoactive medications will be utilized without .a diagnosed specific condition and will include the target behavior .with the goal of reducing the duration and/or dose of the medication. ~Monitor and track progress towards the therapeutic goal (s) . ~Perform gradual dose reductions (GDR) as per regulatory…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not provide measures to prevent and treat Pressure Injuries (PI) while completing wound care for a PI, ensure that pressure relieving air mattress was operational and in continuous working order, and did not document pressure injury assessment including wound staging at least weekly for R12, R31 was not provided off-loading of pressure or repositioned timely. The facility practices had the potential to affect 2 of 3 (R12 and R31) residents reviewed for pressure injuries. This is evidenced by: Example 1 Surveyor reviewed facility policy titled, Prevention and Treatment of Skin Breakdown, noting NPUAP as reference included, in part: Those residents' who experience a break in skin integrity or wounds are provided care and service to heal the skin according to professional standards of care. Professional standards of practice as suggested by Centers for Disease Control and Prevention (CDC) include cleaning and disinfecting patient care equipment,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and policy review, the facility did not establish and maintain an infection prevention and control program when staff did not offer hand hygiene prior to meal service for 3 of 8 residents (R) R209, R210 and R214, or provide wound care in a manner to prevent infection for (R) 42. Findings include: Facility policy titled, Hand Hygiene by Residents, dated June 2017, stated in part .3. Residents are asked and encouraged to perform hand hygiene before and after meals . On 11/30/23 at 12:13 PM, Surveyor observed trays passed to residents on the 500 hall by Registered Nurse (RN) D. R209, R210 and R214 were not offered any hand hygiene in their rooms when the trays arrived. Surveyor asked RN D, Do the residents get hand hygiene offered to them prior to meals being delivered? RN D replied, They all have hand sanitizer in their rooms for the residents to use. Surveyor replied to RN D, These 3 residents observed were not offered any hand hygiene today when I was observing trays passed. RN D replied, Oh. On 11/30/23 at 1:42 PM, Surveyor interviewed Director 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 2.7 | +1.3 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| NICHOLS, STEVEN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2024 |
| SPAULDING, JARED | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/14/2025 |
| BRAUER, AMY | Individual | CORPORATE OFFICER | since 07/25/2024 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | since 07/25/2024 |
| JORGENSEN, DAVID | Individual | CORPORATE OFFICER | since 07/25/2024 |
| SATO, AMI | Individual | CORPORATE OFFICER | since 09/09/2024 |
CMS files one row per role, so the 10 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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 $739K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 525503. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-01, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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.