Cycle 1
Health 2025-02-26 · Fire 2025-02-26
21 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Beaver Dam, WI
Beaver Dam Health Care Center
1-star overall rating with 1-star inspections with abuse icon flag with $144,764 in total fines with 21 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
410 Roedl Ct, Beaver Dam, WI
(920) 887-7191
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bedrock Healthcare
Operator or chain grouping
Approved since
1983-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 1 overall / 1 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
0.35
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.60
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
2.62
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.02
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.42
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.05
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,886
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 67.21% · Performance 77.33% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.97
Baseline 2.50 hours · Performance 3.64 hours · Measure score 2.97 · Achievement 1.97 · Improvement 2.97
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.98% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 14.29% · Lower 95% interval 6.87% |
| Discharge to community | 43.25% |
50.57%
7.3 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 30.3% · Lower 95% interval 27.8% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 28 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | 78.26% |
53.69%
24.6 pts better
|
Numerator 18 · Denominator 23 |
| Discharge mobility score | 73.91% |
50.94%
23 pts better
|
Numerator 17 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 1 · Denominator 28 · Adjusted rate 3.58% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 53 |
| Staff flu vaccination coverage | 18.4% |
42%
23.6 pts worse
|
Numerator 23 · Denominator 125 |
| Discharge function score | 82.61% |
56.45%
26.2 pts better
|
Numerator 19 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · 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 | 34.78% |
25.2%
9.6 pts better
|
Numerator 8 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.6% |
95.7%
5.1 pts worse
|
93.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 89.7% · Q3 88.9% · Q4 89.3% · 4Q avg 90.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.7% |
95.0%
1.3 pts worse
|
95.5%
1.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.2%
0.5 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 3.4% · Q3 1.9% · Q4 0.0% · 4Q avg 2.7% · 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 | 5.8% |
4.9%
0.9 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.1% · Q3 13.3% · Q4 4.2% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.8% |
16.6%
3.8 pts better
|
19.6%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 8.0% · Q3 14.9% · Q4 20.4% · 4Q avg 12.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.3% |
16.7%
10.6 pts worse
|
16.7%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 17.9% · Q3 32.4% · Q4 35.9% · 4Q avg 27.3% · 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 | 8.4% |
21.1%
12.7 pts better
|
16.3%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.7% · Q3 12.9% · Q4 8.8% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.7% |
17.3%
10.6 pts better
|
14.9%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 10.0% · Q3 4.3% · Q4 8.3% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
2.3%
1.7 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
3.0%
2.1 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.7% |
25.5%
6.8 pts better
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 11.2% · Q3 29.2% · Q4 21.2% · 4Q avg 18.7% |
| Percentage of long-stay residents with pressure ulcers | 12.7% |
5.5%
7.2 pts worse
|
5.1%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 11.5% · Q3 14.1% · Q4 16.5% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.9% |
86.8%
14.9 pts worse
|
81.7%
9.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 82.8% · Q2 81.0% · Q3 69.2% · Q4 58.1% · 4Q avg 71.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 28.5% |
15.0%
13.5 pts worse
|
12.0%
16.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 32.4% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.3%
1.3 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.9% · Q3 0.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.0% |
82.2%
9.2 pts worse
|
79.7%
6.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
22.7%
6.1 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 17.6% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
25 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-12-19 · Fire 2022-12-19
52 health deficiencies
Top issue: Quality of Life and Care (16 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-26
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-02-26
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 2025-03-26
E · Potential for more than minimal harm
2025-02-26
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 2025-03-26
E · Potential for more than minimal harm
2025-02-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-02-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-02-26
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-02-26
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-02-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-02-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-02-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-02-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-26
F · Potential for more than minimal harm
2024-03-07
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-04-03
F · Potential for more than minimal harm
2024-03-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-03
F · Potential for more than minimal harm
2024-03-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-03
F · Potential for more than minimal harm
2024-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-03
F · Potential for more than minimal harm
2024-03-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-03
F · Potential for more than minimal harm
2024-03-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-03
F · Potential for more than minimal harm
2024-03-07
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-04-03
F · Potential for more than minimal harm
2024-03-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-03
E · Potential for more than minimal harm
2024-03-07
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 2024-04-03
D · Potential for more than minimal harm
2024-03-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-03
F · Potential for more than minimal harm
2022-12-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-16
F · Potential for more than minimal harm
2022-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-16
F · Potential for more than minimal harm
2022-12-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-16
F · Potential for more than minimal harm
2022-12-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-19
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 2023-01-16
E · Potential for more than minimal harm
2022-12-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-19
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-01-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-11-13
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 2025-12-12
G · Actual harm
2025-03-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-20
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 2025-04-14
D · Potential for more than minimal harm
2025-03-20
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 2025-04-14
D · Potential for more than minimal harm
2025-03-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-14
G · Actual harm
2025-02-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-02-26
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 2025-03-27
F · Potential for more than minimal harm
2025-02-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-02-26
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-02-26
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-02-26
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 2025-03-27
E · Potential for more than minimal harm
2025-02-26
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 2025-03-27
E · Potential for more than minimal harm
2025-02-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-26
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 2025-03-27
D · Potential for more than minimal harm
2025-02-26
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-26
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 2025-03-27
D · Potential for more than minimal harm
2025-02-26
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 2025-03-27
D · Potential for more than minimal harm
2025-02-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-01-02
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 2025-01-23
F · Potential for more than minimal harm
2024-07-16
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-06
J · Immediate jeopardy
2024-06-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-25
G · Actual harm
2024-06-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-25
F · Potential for more than minimal harm
2024-06-25
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 2024-07-25
E · Potential for more than minimal harm
2024-06-25
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-25
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 2024-07-25
D · Potential for more than minimal harm
2024-06-25
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 2024-07-25
D · Potential for more than minimal harm
2024-06-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-25
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-07-25
C · Minimal harm
2024-06-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-07-25
F · Potential for more than minimal harm
2024-03-07
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 2024-04-03
F · Potential for more than minimal harm
2024-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-03
E · Potential for more than minimal harm
2024-03-07
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
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 2024-04-03
D · Potential for more than minimal harm
2024-03-07
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 2024-04-03
D · Potential for more than minimal harm
2024-03-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
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 2024-04-03
D · Potential for more than minimal harm
2024-03-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
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 2024-04-03
D · Potential for more than minimal harm
2024-03-07
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 2024-04-03
D · Potential for more than minimal harm
2024-03-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-04-03
J · Immediate jeopardy
2024-01-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-13
J · Immediate jeopardy
2024-01-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-28
E · Potential for more than minimal harm
2024-01-29
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-02-16
E · Potential for more than minimal harm
2024-01-29
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 2024-02-16
D · Potential for more than minimal harm
2024-01-29
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 2024-02-13
D · Potential for more than minimal harm
2024-01-29
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-02-13
D · Potential for more than minimal harm
2024-01-29
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 2024-02-16
D · Potential for more than minimal harm
2024-01-29
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-02-28
E · Potential for more than minimal harm
2023-12-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-08
E · Potential for more than minimal harm
2023-12-13
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 2024-01-08
D · Potential for more than minimal harm
2023-12-13
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 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F774 · Administration Deficiencies
Health
Help the resident with transportation to and from laboratory services outside of the facility.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-10-30
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 2023-11-20
D · Potential for more than minimal harm
2023-10-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-30
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-08-30
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 2023-09-18
D · Potential for more than minimal harm
2023-08-30
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 2023-09-18
D · Potential for more than minimal harm
2023-08-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-29
G · Actual harm
2023-06-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-06-14
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 2023-07-10
G · Actual harm
2023-05-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-05-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-05-10
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 2023-06-01
D · Potential for more than minimal harm
2023-05-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-04-18
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 2023-05-15
D · Potential for more than minimal harm
2023-03-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-03-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-17
J · Immediate jeopardy
2022-12-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-16
J · Immediate jeopardy
2022-12-19
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 2023-01-16
F · Potential for more than minimal harm
2022-12-19
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 2023-01-16
F · Potential for more than minimal harm
2022-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-16
F · Potential for more than minimal harm
2022-12-19
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 2023-01-16
E · Potential for more than minimal harm
2022-12-19
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 2023-01-16
E · Potential for more than minimal harm
2022-12-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-19
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-19
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-19
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-19
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-19
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-19
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-19
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 2023-01-16
D · Potential for more than minimal harm
2022-12-19
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 2023-01-16
D · Potential for more than minimal harm
2022-12-19
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-19
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 2023-01-16
D · Potential for more than minimal harm
2022-12-19
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-19
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 2023-01-16
Penalties and ownership
What sits behind the stars
$0
2025-02-26
Payment Denial
Payment Denial · denial start 2025-03-27 · 18 days
18 day denial
$46,258
2024-06-25
Fine
Fine · fine $46,258
Fine
$0
2024-06-25
Payment Denial
Payment Denial · denial start 2024-07-25 · 12 days
12 day denial
$49,526
2023-12-13
Fine
Fine · fine $49,526
Fine
$0
2023-12-13
Payment Denial
Payment Denial · denial start 2024-02-20 · 8 days
8 day denial
$11,464
2023-06-14
Fine
Fine · fine $11,464
Fine
$37,516
2023-04-18
Fine
Fine · fine $37,516
Fine
Ownership
Bedrock Hc Wi LLC
5% Or Greater Direct Ownership Interest · Organization
Bedrock Op Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Chopp, Martin
5% Or Greater Indirect Ownership Interest · Individual
Chopp, Pnina
5% Or Greater Indirect Ownership Interest · Individual
Chopp, Pnina
Operational/Managerial Control · Individual
Chopp, Solomon
5% Or Greater Indirect Ownership Interest · Individual
Chopp, Solomon
Operational/Managerial Control · Individual
Grunhut, Shimon
Operational/Managerial Control · Individual
Magar, Namrata
Operational/Managerial Control · Individual
Opal Healthcare Nj LLC
Operational/Managerial Control · Organization
Opal Healthcare Wi LLC
Operational/Managerial Control · Organization
Nearby options
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Hillside Manor
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3-star overall rating with 2-star inspections with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Clearview
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4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Clearview Brain Injury Center
Juneau, WI
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
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