Cycle 1
Health 2025-04-17 · Fire 2025-04-17
22 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Weyauwega, WI
Avina of Weyauwega
1-star overall rating with 1-star inspections with $57,518 in total fines with 22 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
717 E Alfred St, Weyauwega, WI
(920) 867-3121
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aria Healthcare
Operator or chain grouping
Approved since
1984-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.07
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.23
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,357
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9979
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.01
Baseline 18.16% · Performance 18.18% · Measure score 7.01 · Achievement 7.01 · Improvement 0
Healthcare-associated infections
4.86
Baseline 6.65% · Performance 6.38% · Measure score 4.86 · Achievement 4.86 · Improvement 1.13
Total nurse turnover
4.04
Performance 47.17% · Measure score 4.04 · Achievement 4.04 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.99
Baseline 2.65 hours · Performance 3.43 hours · Measure score 1.99 · Achievement 1.24 · Improvement 1.99
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.96% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 14.06% · Lower 95% interval 7.54% |
| Discharge to community | 32.58% |
50.57%
18 pts worse
|
Worse than the National Rate · Eligible stays 55 · Observed rate 20% · Lower 95% interval 19.92% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 87.1% |
95.27%
8.2 pts worse
|
Numerator 27 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 20% |
53.69%
33.7 pts worse
|
Numerator 4 · Denominator 20 |
| Discharge mobility score | 45% |
50.94%
5.9 pts worse
|
Numerator 9 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.38% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 3.23% · Lower 95% interval 3.46% |
| Staff COVID-19 vaccination coverage | 3.9% |
8.2%
4.3 pts worse
|
Numerator 3 · Denominator 77 |
| Staff flu vaccination coverage | 36.7% |
42%
5.3 pts worse
|
Numerator 40 · Denominator 109 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 10 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
95.7%
About the same
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 92.5% · Q3 97.1% · Q4 93.5% · 4Q avg 95.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.7% |
95.0%
0.7 pts better
|
95.5%
0.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.2%
1.1 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 2.9% · Q4 3.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
4.9%
1.7 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 12.1% · Q3 3.3% · Q4 7.1% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.8% |
16.6%
16.2 pts worse
|
19.6%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 29.4% · Q3 33.3% · Q4 31.0% · 4Q avg 32.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
16.7%
1.2 pts better
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 16.7% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.4% |
21.1%
4.3 pts worse
|
16.3%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.8% |
17.3%
11.5 pts better
|
14.9%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 3.2% · Q3 3.3% · Q4 6.9% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
3.0%
2.3 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
25.5%
0.6 pts better
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 38.2% · Q3 20.2% · Q4 23.4% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 9.1% |
5.5%
3.6 pts worse
|
5.1%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 10.5% · Q3 11.6% · Q4 5.6% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.2% |
86.8%
3.6 pts worse
|
81.7%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.5% · Q2 92.2% · Q3 81.3% · Q4 73.1% · 4Q avg 83.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
15.0%
1.1 pts better
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 14.3% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.7% |
82.2%
12.5 pts worse
|
79.7%
10 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.0% |
22.7%
5.3 pts worse
|
23.9%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.0% · Observed 28.6% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-14 · Fire 2024-02-14
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-17
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-17
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-17
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-17
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-17
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-17
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-15
F · Potential for more than minimal harm
2024-02-14
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-03-13
F · Potential for more than minimal harm
2024-02-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-13
F · Potential for more than minimal harm
2024-02-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-13
E · Potential for more than minimal harm
2024-02-14
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-06-08
E · Potential for more than minimal harm
2024-02-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-02-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-14
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-03-13
F · Potential for more than minimal harm
2023-01-12
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-02-28
F · Potential for more than minimal harm
2023-01-12
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-02-28
F · Potential for more than minimal harm
2023-01-12
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-02-28
F · Potential for more than minimal harm
2023-01-12
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-02-28
F · Potential for more than minimal harm
2023-01-12
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-02-28
F · Potential for more than minimal harm
2023-01-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-28
E · Potential for more than minimal harm
2023-01-12
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-02-28
E · Potential for more than minimal harm
2023-01-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-02-28
E · Potential for more than minimal harm
2023-01-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-28
E · Potential for more than minimal harm
2023-01-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-02-28
D · Potential for more than minimal harm
2023-01-12
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-02-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-07
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-12-01
D · Potential for more than minimal harm
2025-08-27
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2025-09-22
D · Potential for more than minimal harm
2025-08-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-09-22
D · Potential for more than minimal harm
2025-08-27
F742 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-09-22
D · Potential for more than minimal harm
2025-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-23
K · Immediate jeopardy
2025-04-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-15
J · Immediate jeopardy
2025-04-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-17
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-05-22
E · Potential for more than minimal harm
2025-04-17
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-17
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-05-15
C · Minimal harm
2025-04-17
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-02-18
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-14
G · Actual harm
2025-01-14
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-14
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-10
D · Potential for more than minimal harm
2024-10-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-24
J · Immediate jeopardy
2024-07-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-07-24
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-02-14
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-14
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-14
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-14
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-13
G · Actual harm
2023-11-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-11-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-22
F · Potential for more than minimal harm
2023-01-12
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2023-02-14
F · Potential for more than minimal harm
2023-01-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-28
F · Potential for more than minimal harm
2023-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-14
F · Potential for more than minimal harm
2023-01-12
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-02-06
F · Potential for more than minimal harm
2023-01-12
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-02-06
E · Potential for more than minimal harm
2023-01-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-02-14
E · Potential for more than minimal harm
2023-01-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-12
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-12
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-14
Penalties and ownership
What sits behind the stars
$0
2025-04-17
Payment Denial
Payment Denial · denial start 2025-05-17 · 5 days
5 day denial
$24,840
2025-01-14
Fine
Fine · fine $24,840
Fine
$14,702
2024-07-24
Fine
Fine · fine $14,702
Fine
$17,976
2023-11-01
Fine
Fine · fine $17,976
Fine
Ownership
Brandman, Joseph
5% Or Greater Direct Ownership Interest · Individual
Topper, Aaron
5% Or Greater Direct Ownership Interest · Individual
Aa Healthcare Management, LLC
Operational/Managerial Control · Organization
Brandman, Joseph
Operational/Managerial Control · Individual
Mueller, David
W-2 Managing Employee · Individual
Topper, Aaron
Operational/Managerial Control · Individual
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