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Wisconsin Dells Health Services

300 Race St., Wisconsin Dells, WI 53965 · For profit - Corporation · 90 certified beds · (608) 254-2574 Medicare & Medicaid certified

Call the home — (608) 254-2574 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • 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)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

3/5
CMS overall
3 of 5
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

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
320 Race St · (800) 200-7178 · Call to confirm hours
Pharmacy
300 State Highway 13 · (608) 254-5760 · Call to confirm hours
Grocery
216 Washington Ave · (608) 254-8313 · Call to confirm hours
Park
727 Broadway · (608) 254-7458 · Typically dawn to dusk
Place of worship
N9475 Pine Valley Ln · (608) 254-8352

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 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased18.4%16.1%15.4%worse
Long-stay residents who lose too much weight7.7%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%2.1%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.2%2.7%2.0%better
Long-stay residents with depressive symptoms13.2%5.7%6.5%worse
Long-stay residents who were physically restrained0.6%0.1%0.1%worse
Long-stay residents with falls causing major injury2.9%3.3%3.3%better
Long-stay residents whose ability to walk worsened27.8%18.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication6.9%16.9%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers4.2%5.0%4.7%better
Long-stay residents with worsening bladder/bowel control29.0%24.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table15.9%15.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication3.1%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine77.8%82.2%79.4%typical
Short-stay residents rehospitalized after admission15.0%23.1%22.6%better
Short-stay residents with an outpatient ER visit10.0%15.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.481.661.67better
Long-stay outpatient ER visits per 1,000 resident days1.062.291.80better

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.

55.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 93 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.3%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
55.9%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 55.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 34 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF55.3%CMS range 47.0–63.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 7.4–15.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge55.9%56.6%Oct 2024–Sep 2025CMS 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 discharge47.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge58.8%50.0%Oct 2024–Sep 2025CMS 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 identified97.5%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 4.0–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.94
RN hours/ resident / day
0.27
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.44
Total nurse hours/ resident / day
0.75
RN hoursweekends
37.5%
Total nursing turnover
23.1%
RN turnover

How full it usually is: this home is certified for 90 beds and averages 46.1 residents a day — about 51% occupied, or roughly 44 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 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.94 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 3.20 hrs/resident/day on weekends vs 3.53 on weekdays — 10% thinner on weekends. RN hours go from 1.02 to 0.75 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.

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

Inspection trend

3
deficiencies at the latest standard inspection (2026-04-30)
8
at the previous standard inspection (2025-03-11)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · Ecited before2026-04-30 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 9 residents who reside on the memory care unit at the facility.Surveyor observed the microwave and refrigerator in the kitchenette to be unkept. The microwave had food splatters all over the inside of the microwave. The refrigerator had crumbs and food spilled on the inside of the refrigerator.Evidenced by:The facility policy, Microwave Oven, dated, 7/21/22, states in part;.The microwave oven will be kept clean, sanitized, and odor free. The microwave oven interior should be cleaned after each use as needed, and at a minimum, after each meal service.The facility policy, Cleaning Instructions: Refrigerators, dated, 7/21/22, states in part;.The refrigerator will be cleaned thoroughly inside and outside with a detergent and followed by a sanitizer at least once every month, or as needed. Spills and leaks will be cleaned as they occur.On 4/29/26 at 10:35 AM, Surveyor observed 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-30 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents advanced directive was signed by the resident or resident representative for 1 (R28) of 12 residents reviewed for advance directives.R28 did not have an advanced directive signed by their Power of Attorney. Evidenced by:The facility policy, Obtaining and Communicating Code Status, dated, [DATE], states in part;.It is the policy of this facility to adhere to residents rights to direct their code status. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information.R28 was admitted to the facility on [DATE] and R28 has an activated power of attorney in place. R28's Cardiopulmonary Resuscitation/Do Not Resuscitate (CPR/DNR) Preference Form indicates, R28 wishes to be DNR. The document is dated [DATE] and does not have the Power of Attorney's signature.On [DATE] at 1:15 PM, NHA A (Nursing Home Administrator) indicated the facility…

    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 · D2026-04-30 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 proper use of bed rails for 1 (R5) of 1 Residents reviewed for bed rails.R5 is care planned for side rails up with cares only. R5 was observed in bed, with side rails raised and no staff present.Evidenced by:The facility's Proper Use of Side Rails policy, dated 9/23/22, states, in part: It is the policy of this facility to utilize a person-centered approach when determining the use of side rails, also known as bed rails.If used, the facility ensures correct installation, use, and maintenance of the rails.5. The use of side rails will be specified in the resident's plan of care.c. Parameters for use shall be clearly defined, such as quarter rails or at certain times. 6. The facility will provide ongoing monitoring and supervision of side rail/bed rail use for effectiveness, assessment of need and determination when or if the side rail/bed rail will be discontinued. Responsibilities are specified as follows: a. Direct care staff will be responsible for care and treatment in accordance with the plan 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-08-07 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review, the facility failed to have an effective pest control program in place to prevent pests and rodents from entering the building through damaged exterior doors which lead into the kitchen. This has the potential to affect the census of 52. Findings include:During an initial inspection of the kitchen, on 08/06/25 at 1:20 PM, the following concerns were observed:1.There were two small black droppings in the dry storage room which appeared to be mouse droppings.2.The exterior door next to the dry storage area was observed to have gaps at the bottom of the door where light from outside was observed providing access to pests and/or rodents. A secondary door in between the exterior and interior of the building, directly in front of the exterior door, was observed to have a gap at the bottom corner of the door.3.The door to the dry storage room was not sealed across the bottom of the door, providing access to pests and/or rodents.4.The exterior door, identified as the door utilized for food service delivery, was observed to have…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-03-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility did not maintain a safe and sanitary environment in which food is prepared, stored and distributed. This has the potential to affect all 44 residents who reside in the facility. Surveyor observed the facility's freezer to have frozen condensation attached to the ceiling and fallen pieces of frozen condensation on top of and inside of boxes of unsealed food causing potential for contamination. Surveyor observed a mixer to be stored covered and unclean. Supplements in the medication rooms were not dated. Evidenced by: Example 1 Facility policy, titled Food Storage: Cold Foods, undated, includes: . All . foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of FDA (Food and Drug Administration) Food Code . All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . On 3/9/25 at 9:04 AM, during initial tour of the facility's kitchen, Surveyor and DM K observed frozen drips suspended from the ceiling in 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-03-11 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection, this has the potential to affect the census (44), 1 of 4 residents (R10) wound care observations with hand hygiene concerns, and 1 of 3 residents (R37) medication pass observations with hand hygiene concerns. The facility is not monitoring the temperature of 2 of their 3 water heaters as part of their control measures for Water Management Program. The facilities Policy and Procedure for Pneumococcal Vaccine is not up to date. The facility did not identify an outbreak on the date it started. There was a breach in infection control for R10 when LPN F did not perform appropriate hand hygiene with wound care. There was a breach in infection control for R37 when LPN F did not perform appropriate hand hygiene with medication…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-11 · 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 observation, interview, and record review, the facility did not ensure that the residents environment remained free of accidents and hazards for 1 of 3 (R25) reviewed for falls and 1 of 1 (R7) reviewed for accidents and hazards. R25 did not have fall interventions in place after 2 falls. Surveyor observed R7's motorized wheelchair charging in the hallway and not behind a fire safe door. This is evidenced by: The facility's policy titled Fall Prevention and Management Guidelines, revised 7/18/24, states in part: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. Provide interventions that address unique risk factors measured by the risk assessment tool. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness. The plan…

    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 · D2025-03-11 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure 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

    Based on observation, interview, and record review, the facility did not ensure residents who are fed and receive medication by G-tube (Gastrostomy tube, a thin flexible tube inserted through a small incision in the abdomen and into the stomach, used to provide nutrition and fluids) receive the appropriate treatment and services. This affects 1 of 2 residents (R22) reviewed for tube feedings. The facility did not properly check placement of R22's G-tube prior to administering tube feeding. This is evidenced by: The facility's policy titled Verifying Placement of Tube Feeding, revised 8/10/22, states in part: It is the practice of this facility to ensure proper placement of feeding tubes prior to beginning a feeding, flushing the tube, or before administering medications via feeding tube. Before beginning a feeding, flushing the tube, or administering a medication via the feeding tube, proper placement and functioning will be verified. Verify tube placement: For gastrostomy tubes, check that the enteral retention device is properly approximated to the abdominal wall by gently tugging…

    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 · D2025-03-11 · 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 observation, interview, and record review the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 of 2 residents (R39) reviewed for oxygen. R39 did not have oxygen tubing changed on a weekly basis. Evidenced by: R39 admitted to the facility on [DATE] and has diagnoses that include, in part: pneumonia due to other specified infectious organisms (infection that causes inflammation of the lungs); chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing breathing problems); acute on chronic systolic congestive heart failure (a condition that causes the heart to pump less effectively causing shortness of breath, weakness and fatigue. R39's Minimum Data Set (MDS), dated [DATE], indicates R39's Brief Interview of Mental Status (BIMS) is a 15, indicating that R39 is cognitively intact. R39's Physician Orders state, in part: *Oxygen at 1-4 L/min (liters per minute) via nasal cannula to keep…

    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 · D2025-03-11 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure that a resident who requires dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (R39 and R33) reviewed for dialysis. R39 is receiving dialysis services. R39's care plan does not indicate how to handle an emergency situation with R 39's dialysis port and staff were not able to appropriately verbalize how to handle an emergency situation. R33 is receiving dialysis services. R33's care plan does not indicate how to handle an emergency situation with R33's dialysis port and staff were not able to appropriately verbalize how to handle an emergency situation. Evidenced by: The facility's Hemodialysis policy, dated 9/10/23, states, in part: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will…

    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
Show the remaining 11 citations
  • Potential for harm · D2025-03-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the effective monitoring of psychotropic medications for 1 of 5 residents (R35) reviewed for unnecessary medications. R35 was started on Trazadone (antidepressant) for sleep. R35's comprehensive care plan and medical record does not contain sleep monitoring or tracking to assess the effectiveness of this medication. This is evidenced by: The facility policy entitled, Psychotropic Medications, dated 10/24/2022, states in part: .4. The indications for use of any psychotropic drug will be documented in the medical record .b. For Psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician .ii. Non-pharmacological interventions that have been attempted, and target symptoms for monitoring shall be included in the documentation .13. The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be…

    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 · D2025-03-11 · 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 — the official record, unedited, may be distressing

    Based on observation and interview the facility did not ensure drugs and biologicals are labeled in accordance with currently accepted professional standards 1 of 1 medication carts observed. The medication cart on the 400 hall had two tubes of open and used medicated ointment with no resident names. Evidenced by: Surveyor observed an open, used tube of muscle rub and an open, used tube of hydrocortisone acetate 1% cream in the drawer of the 400 hall medication cart. Surveyor asked LPN G if the tubes were both open and used. LPN G stated yes. Surveyor asked LPN G what resident the tubes were for. LPN G stated no idea, the tubes are not labeled. On 3/11/25 at 10:35 AM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist) Surveyor asked how long nutritional supplements are good after being opened. DON/IP B stated 3 days. Surveyor asked how staff would know if a supplement is good if there is no use by date. DON/IP B stated there should be a date. Surveyor asked if tubes of ointment are expected to be labeled with a resident's name. DON/IP B stated yes.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-03 · 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 interview and record review, the facility failed to ensure staff were following the plan of care, failed to complete a root cause analysis, and failed to ensure fall interventions were functioning properly for 1 of 3 residents (R3) reviewed for falls. R3 has severe cognitive impairment. R3's care plan states R3 is assist of 1 for transfer resident was observed transferring and ambulating independently. Staff were not aware R3 required assistance with transfer and ambulation and did not know a fall intervention was not functioning. Evidenced by: The Facility Fall Prevention and Management Guidelines revised 7/18/24, includes, in part: each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. 3. The nurse will initiate interventions to help prevent falls on the resident's baseline care plan. 6. Each residents risk factors and environmental hazards…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-21 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not make prompt efforts to resolve resident grievances for 1 resident (R1) out of 3 sampled residents. R1's Activated Power of Attorney (APOA) informed the facility that R1 did not receive morning (AM) medications until noon. The facility failed to make prompt efforts to resolve the grievance. Evidenced by: The facility policy, Grievance Policy, dated 7/22, states, in part; Policy: The facility will seek to resolve concerns, complaints or grievances and provide residents, responsible parties, staff and others feedback and resolutions in a timely manner . R1 was admitted to the facility on [DATE] with diagnoses including dementia, weakness, obesity, fibromyalgia, depression, and anxiety. R1's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/19/24, indicates R1 has a Brief Interview for Mental Status (BIMS) score of 11 indicating R1 is moderately cognitively impaired. R1 has an activated power of attorney. On 5/21/24 at 11:00 AM, RN…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-21 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 interview and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 out of 3 sampled residents (R1 and R3). On 5/19/24, R1 did not receive morning (AM) medications until noon. On 5/19/24, R3 did not receive scheduled 7:30 AM and 8:00 AM medications timely. This resulted in 20 medication timing errors. Evidenced by Facility policy, Medication Administration: General Guidelines, dated 1/23 states, in part; .Policy Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication .1. Medications are administered in accordance with written orders of the prescriber .14.Medications…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-21 · 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

    Based on interview and record review, the facility did not ensure residents are free of significant medication errors for 1 of 3 total sampled residents (R3). The facility scheduled R3's Metoprolol Succinate ER to be administered at 7:30 AM and 7:30 PM. On 5/18 and 5/19/24, the facility administered R3's morning dose of Metoprolol late and administered the evening dose of Metropolol less than 12 hours after the morning dose. This resulted in four (4) timing errors. As evidenced by Facility policy, Medication Administration: General Guidelines, dated 1/23 states, in part; .Policy Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication .1. Medications are administered in accordance with written orders of the prescriber .14.Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered…

    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 · Fcited before2024-04-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, document review, and review of the United States (US) Food Code, Dietary Aide (DA) J failed to test a low temperature dish machine's final rinse chemical level properly. In addition, two drink items were not labeled and located in the dietary reach-in refrigerator. The deficient practice affected 46 out of 48 residents and could cause the potential spread of foodborne illness. Findings include: Review of the US Food Code 2022 indicated, .Explaining correct procedures for cleaning and sanitizing utensils and food-contact surfaces of equipment. Employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused. Review of the US Food Code 2022 indicated, . an employee shall eat, drink.only in designated areas where the contamination of exposed food, clean equipment, utensils, and linens . Review of the ECOLAB .Chlorine test strip container indicated, .Immerse the strip in sample and remove immediately .Hold strip level (do not shake off excess sample) .Evaluate the color between 5 and 10 seconds after removing the test…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-04-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment this has the potential to affect the census of 48 and 2 of 6 residents observed on EBP protocol. The facility did not have an up-to-date process to ensure all staff have been fit tested annually for use of N95 masks. Enhanced Barrier Precautions were not appropriately implemented and maintained for two residents R27 and R16. This is evidenced by: The Facilities Policy and Procedure entitled N95 Fit Testing dated 10/16/23, documents in part: All staff that work in direct resident care will have an initial and annual fit-test for respirator use in accordance with Occupational Safety Health Administration (OSHA) regulations .The initial fit test will occur prior to initial use of the respirator. The center's Infection Preventionist will authorize the assignments of qualified fit-testers and will implement an annual fit-testing…

    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 · D2024-04-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure a resident with a catheter receives appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (R36) reviewed for catheter care out of total sample of 14. Staff did not perform appropriate hand hygiene while providing catheter care. There was no barrier placed under supplies on the bedside table during the catheter care. Staff reused a washcloth after cleansing with it by placing it back in the wash basin and using it for the second time on resident's peri area. Staff placed dirty wash cloths directly on bedside table and did not disinfect bedside table after use. Evidenced by: The facility policy entitled Hand Hygiene, dated 11/2/22, states, in part: . Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . Policy Explanation and Compliance…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-17 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder (PTSD), receives appropriate treatment and services to correct the assessed problem or attain the highest practical mental and psychosocial well-being for 1 of 1 residents reviewed for PTSD out of 14 sampled residents (R26). R26 was listed as having a diagnosis of PTSD and his care plan is not person centered, as it does not specify triggers, symptoms to monitor for or interventions to use to ensure R26 is reaching his highest practical mental and psychosocial well-being. This is evidenced by: Per CMS (Centers for Medicare and Medicaid Services), .Although PTSD is commonly viewed as a disorder experienced only by military veterans, it is not exclusively a consequence of combat or war zone exposure. Individuals who have been physically or sexually assaulted or who experienced…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-27 · 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, observation and interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (R) R5. Findings include: Facility policy entitled: Comprehensive Care Plan, reviewed and revised 09/23/2022, states: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Under the section entitled Policy Explanation and Compliance Guidelines it states in part .8. Staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. R5 was admitted to facility on 01/30/24 for short term stay with goal 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to NORTH SHORE HEALTHCARE — 59 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.7+0.3 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 4 of 53.4+0.6 vs chain
Quality measures 4 of 52.5+1.5 vs chain
The other 58 homes this chain runs (chain average 2.7★, per CMS)
1 of 5Elroy Health ServicesElroy, WI 1 of 5Florence Health ServicesFlorence, WI 1 of 5Hopkins Restorative Care CenterHopkins, MN 1 of 5La Crescent Health ServicesLa Crescent, MN 1 of 5Little Chute Health ServicesLittle Chute, WI 1 of 5Minot Health And Rehab, LLCMinot, ND 1 of 5Plymouth Health ServicesPlymouth, WI 1 of 5Rochester Restorative Care CenterRochester, MN 1 of 5Sheboygan Progressive Health ServicesSheboygan, WI 1 of 5Williams Bay Health ServicesWilliams Bay, WI 1 of 5Wisconsin Rapids Health ServicesWisconsin Rapids, WI 2 of 5Birch Hill Health ServicesShawano, WI 2 of 5Colonial Health ServicesColby, WI 2 of 5Evergreen Health ServicesShawano, WI 2 of 5Green Bay Health ServicesGreen Bay, WI 2 of 5Heritage Health ServicesPort Washington, WI 2 of 5Lake Country Health ServicesOconomowoc, WI 2 of 5Lancaster Health ServicesLancaster, WI 2 of 5Maple Ridge Health ServicesMilwaukee, WI 2 of 5Menomonee Falls Health ServicesMenomonee Falls, WI 2 of 5Mineral Point Health ServicesMineral Point, WI 2 of 5Soldiers Grove Health ServicesSoldiers Grove, WI 2 of 5Stevens Point Health ServicesStevens Point, WI 2 of 5Sunrise Health ServicesMilwaukee, WI 2 of 5Three Oaks Health ServicesMarshfield, WI 2 of 5Tomahawk Health ServicesTomahawk, WI 2 of 5Whitewater Health ServicesSt Charles, MN 2 of 5Willowcrest Health ServicesSouth Milwaukee, WI 3 of 5Cedarburg Health ServicesCedarburg, WI 3 of 5Court Manor Health ServicesAshland, WI 3 of 5Hayward Health ServicesHayward, WI 3 of 5Homestead Health ServicesNew Holstein, WI 3 of 5Mercy Health ServicesMilwaukee, WI 3 of 5Morningside Health ServicesSheboygan, WI 3 of 5Oakwood Health ServicesAltoona, WI 3 of 5Randolph Health ServicesRandolph, WI 3 of 5Rib Lake Health ServicesRib Lake, WI 3 of 5River's Bend Health ServicesManitowoc, WI 3 of 5Riverview Health ServicesTomahawk, WI 3 of 5Sheboygan Health ServicesSheboygan, WI

Showing 40 of 58; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
NSHC WISCONSIN LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/04/2017
CIBC BANK USAOrganization5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
BAUMANN, TROYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 04/04/2017
HOEHN, JEFFREYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 04/04/2017
CLIFTONLARSONALLEN LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/13/2025
CONTINUUM THERAPY PARTNERS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
NORTH SHORE HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/04/2017
NSH REHAB LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2025
WIPFLI LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2025
BELONGIA, CHRISTINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2019
FLYGT, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2023
GEE, DARRENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/30/2021
GREER, LAURENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/29/2023
HAMMERLY, JORDYNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/27/2022
PATZER, COLLEENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/14/2023
PURTELL, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2018
NSH 300 RACE STREET LLCOrganizationADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 33 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$7.3M
Net patient revenuemost recent cost report
+11.5%
Operating marginrevenue minus expenses
$363K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 39%Medicare 16%Other / private 45%

This home reported $363K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$332per resident / day
operating cost
$10,080per month
≈ monthly operating cost
$375per day
avg. revenue, all payers

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

What families pay in WI

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525391. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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