Cycle 1
Health 2024-09-27 · Fire 2024-09-27
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
19 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Lodi, WI
Dove Healthcare - Lodi
2-star overall rating with 2-star inspections with $24,183 in total fines with 2 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
700 Clark St, Lodi, WI
(608) 592-3241
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Dove Healthcare
Operator or chain grouping
Approved since
1992-12-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 3 overall / 3 health / 4 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
0.58
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.97
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.27
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.43
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
0.60
CMS adjusted RN staffing hours
Adjusted total hours
4.45
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
66%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,090
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.88
Performance 20.10% · Measure score 2.88 · Achievement 2.88 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.92
Baseline 7.09% · Performance 6.96% · Measure score 2.92 · Achievement 2.92 · Improvement 0.13
Total nurse turnover
0
Baseline 69.77% · Performance 98.08% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.42
Baseline 2.90 hours · Performance 3.45 hours · Measure score 1.42 · Achievement 1.31 · Improvement 1.42
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.58% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 6.35% · Lower 95% interval 6.69% |
| Discharge to community | 43.33% |
50.57%
7.2 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 34.62% · Lower 95% interval 32.38% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 46 · Denominator 46 |
| Falls with major injury | 2.17% |
0.77%
1.4 pts worse
|
Numerator 1 · Denominator 46 |
| Discharge self-care score | 29.73% |
53.69%
24 pts worse
|
Numerator 11 · Denominator 37 |
| Discharge mobility score | 27.03% |
50.94%
23.9 pts worse
|
Numerator 10 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 2.17% |
2.29%
0.1 pts better
|
Numerator 1 · Denominator 46 · Adjusted rate 1.91% |
| Healthcare-associated infections requiring hospitalization | 6.96% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 6.45% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 17.24% |
8.2%
9 pts better
|
Numerator 10 · Denominator 58 |
| Staff flu vaccination coverage | 63.3% |
42%
21.3 pts better
|
Numerator 69 · Denominator 109 |
| Discharge function score | 35.14% |
56.45%
21.3 pts worse
|
Numerator 13 · Denominator 37 |
| 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 | 55% |
25.2%
29.8 pts better
|
Numerator 11 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.6
1 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 1.9 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.2
0.1 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.7 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
95.7%
3.1 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.6% · Q3 97.8% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
95.0%
3 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.2%
0.9 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.4% · Q3 0.0% · Q4 2.4% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.8% |
5.0%
3.8 pts worse
|
11.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 10.0% · Q4 20.0% · 4Q avg 8.8% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
4.9%
0.9 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.5% · Q3 2.9% · Q4 3.4% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.1% |
16.6%
3.5 pts better
|
19.6%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 15.6% · Q3 11.1% · Q4 6.5% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.3% |
16.7%
7.6 pts worse
|
16.7%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 21.4% · Q3 27.6% · Q4 23.1% · 4Q avg 24.3% · 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 | 9.7% |
21.1%
11.4 pts better
|
16.3%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.7% |
17.3%
6.6 pts better
|
14.9%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 6.7% · Q3 5.9% · Q4 10.3% · 4Q avg 10.7% · 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 | 1.2% |
3.0%
1.8 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.2% |
25.5%
8.3 pts better
|
19.8%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 20.7% · Q3 9.2% · Q4 20.0% · 4Q avg 17.2% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.5%
0.2 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.7% · Q3 4.3% · Q4 7.4% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
86.8%
12.4 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.5% |
15.0%
1.5 pts better
|
12.0%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 12.0% · Expected 10.0% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.3% |
82.2%
3.1 pts better
|
79.7%
5.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.2% |
22.7%
8.5 pts better
|
23.9%
9.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 12.0% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-29 · Fire 2023-08-29
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Cycle 3
Health 2022-05-24 · Fire 2022-05-24
33 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-27
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-10-26
F · Potential for more than minimal harm
2024-09-27
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-27
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 2024-10-17
F · Potential for more than minimal harm
2024-09-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-09-27
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-10-26
E · Potential for more than minimal harm
2024-09-27
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-10-26
E · Potential for more than minimal harm
2024-09-27
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-27
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-27
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-27
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-27
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-27
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 2024-10-17
F · Potential for more than minimal harm
2023-08-29
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-09-25
F · Potential for more than minimal harm
2023-08-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-25
F · Potential for more than minimal harm
2023-08-29
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 2023-09-25
F · Potential for more than minimal harm
2023-08-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-25
E · Potential for more than minimal harm
2023-08-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-25
E · Potential for more than minimal harm
2023-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-25
E · Potential for more than minimal harm
2023-08-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-29
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 2023-09-25
D · Potential for more than minimal harm
2023-08-29
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-29
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-12-20
F · Potential for more than minimal harm
2022-05-24
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-07-06
F · Potential for more than minimal harm
2022-05-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-05-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-15
E · Potential for more than minimal harm
2022-05-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-06-15
E · Potential for more than minimal harm
2022-05-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-06
E · Potential for more than minimal harm
2022-05-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-07-06
E · Potential for more than minimal harm
2022-05-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-06-14
E · Potential for more than minimal harm
2022-05-24
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-07-06
D · Potential for more than minimal harm
2022-05-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-06-15
D · Potential for more than minimal harm
2022-05-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-06-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-14
F · Potential for more than minimal harm
2024-09-27
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 2024-10-17
J · Immediate jeopardy
2024-08-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-08-26
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-08-26
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 2024-09-18
D · Potential for more than minimal harm
2024-03-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-09
F · Potential for more than minimal harm
2023-08-29
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 2023-09-25
F · Potential for more than minimal harm
2023-08-29
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-09-25
E · Potential for more than minimal harm
2023-08-29
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 2023-09-25
E · Potential for more than minimal harm
2023-08-29
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 2023-09-25
D · Potential for more than minimal harm
2023-08-29
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 2023-09-25
D · Potential for more than minimal harm
2023-08-29
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 2023-09-25
D · Potential for more than minimal harm
2023-08-29
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 2023-09-25
D · Potential for more than minimal harm
2023-08-29
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-29
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 2023-09-25
D · Potential for more than minimal harm
2023-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-29
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 2023-09-25
F · Potential for more than minimal harm
2023-03-29
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 2023-04-21
E · Potential for more than minimal harm
2023-03-29
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 2023-04-21
E · Potential for more than minimal harm
2023-03-29
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 2023-04-21
D · Potential for more than minimal harm
2023-03-29
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-29
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 2023-04-21
D · Potential for more than minimal harm
2023-03-29
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 2023-04-21
D · Potential for more than minimal harm
2023-03-29
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 2023-04-21
D · Potential for more than minimal harm
2023-03-29
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-29
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 2023-04-21
D · Potential for more than minimal harm
2023-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-21
B · Minimal harm
2023-03-29
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 2023-04-21
G · Actual harm
2022-05-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-06-27
F · Potential for more than minimal harm
2022-05-24
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-06-27
F · Potential for more than minimal harm
2022-05-24
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2022-06-27
F · Potential for more than minimal harm
2022-05-24
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2022-06-27
F · Potential for more than minimal harm
2022-05-24
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-06-27
F · Potential for more than minimal harm
2022-05-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-06-27
F · Potential for more than minimal harm
2022-05-24
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 2022-06-27
F · Potential for more than minimal harm
2022-05-24
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 2022-06-27
E · Potential for more than minimal harm
2022-05-24
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-06-27
E · Potential for more than minimal harm
2022-05-24
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2022-06-27
E · Potential for more than minimal harm
2022-05-24
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-06-27
D · Potential for more than minimal harm
2022-05-24
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 2022-06-27
D · Potential for more than minimal harm
2022-05-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-05-24
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 2022-06-27
D · Potential for more than minimal harm
2022-05-24
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-05-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-06-16
D · Potential for more than minimal harm
2022-05-24
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 2022-06-27
D · Potential for more than minimal harm
2022-05-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-22
D · Potential for more than minimal harm
2022-05-24
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-06-27
D · Potential for more than minimal harm
2022-05-24
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 2022-06-27
C · Minimal harm
2022-05-24
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-06-27
C · Minimal harm
2022-05-24
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-06-27
Penalties and ownership
What sits behind the stars
$14,433
2024-08-26
Fine
Fine · fine $14,433
Fine
$9,750
2023-03-29
Fine
Fine · fine $9,750
Fine
Ownership
Wisconsin 3 Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Markovits, Isaak
5% Or Greater Indirect Ownership Interest · Individual
Richland, Ilan
5% Or Greater Indirect Ownership Interest · Individual
Markovits, Isaak
Corporate Director · Individual
Richland, Ilan
Operational/Managerial Control · Individual
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