Cycle 1
Health 2024-11-14 · Fire 2024-11-14
20 health deficiencies
Top issue: Resident Rights (5 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Watertown, WI
Watertown Health Care Center
1-star overall rating with 1-star inspections with $276,120 in total fines with 20 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
121 Hospital Dr, Watertown, WI
(920) 261-9220
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bedrock Healthcare
Operator or chain grouping
Approved since
1983-07-01
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
0.52
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.64
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
2.94
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
2.67
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.12
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,440
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9929
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.92
Baseline 20.60% · Performance 18.22% · Measure score 6.92 · Achievement 6.92 · Improvement 6.16
Healthcare-associated infections
5.19
Baseline 7.86% · Performance 6.28% · Measure score 5.19 · Achievement 5.19 · Improvement 5.01
Total nurse turnover
3.02
Baseline 66.67% · Performance 51.95% · Measure score 3.02 · Achievement 2.87 · Improvement 3.02
Adjusted total nurse staffing
0.85
Baseline 3.02 hours · Performance 3.32 hours · Measure score 0.85 · Achievement 0.85 · Improvement 0.58
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.48% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 7.34% · Lower 95% interval 6.8% |
| Discharge to community | 49% |
50.57%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 90 · Observed rate 43.33% · Lower 95% interval 39.36% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 88% |
95.27%
7.3 pts worse
|
Numerator 22 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 1 · Denominator 25 · Adjusted rate 4.59% |
| Healthcare-associated infections requiring hospitalization | 6.28% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 3.92% · Lower 95% interval 3.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 108 |
| Staff flu vaccination coverage | 52.53% |
42%
10.5 pts better
|
Numerator 52 · Denominator 99 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · 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 |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.7 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.8 |
2.2
1.6 pts worse
|
1.8
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 4.5 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.2%
0.1 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.4% · Q3 1.8% · Q4 1.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
5.0%
1.6 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 1.9% · Q3 2.1% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
4.9%
1.4 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 4.1% · Q4 6.1% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.2% |
16.6%
0.6 pts worse
|
19.6%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 15.1% · Q3 14.3% · Q4 16.3% · 4Q avg 17.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.1% |
16.7%
14.4 pts worse
|
16.7%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 31.4% · Q3 27.8% · Q4 26.8% · 4Q avg 31.1% · 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 | 16.8% |
21.1%
4.3 pts better
|
16.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 11.0% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.9% |
17.3%
7.4 pts better
|
14.9%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 11.5% · Q3 4.2% · Q4 8.2% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.7% |
2.3%
0.4 pts worse
|
1.0%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.4% · Q3 4.2% · Q4 1.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
3.0%
0.4 pts better
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.5% · Q3 1.8% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.7% |
25.5%
1.2 pts worse
|
19.8%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 35.6% · Q3 14.4% · Q4 33.1% · 4Q avg 26.7% |
| Percentage of long-stay residents with pressure ulcers | 13.5% |
5.5%
8 pts worse
|
5.1%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 14.3% · Q3 9.8% · Q4 14.1% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.5% |
86.8%
2.3 pts worse
|
81.7%
2.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 95.7% · Q3 88.9% · Q4 56.8% · 4Q avg 84.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
15.0%
1.2 pts better
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 13.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.3%
1 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 2.5% · Q4 4.4% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.0% |
82.2%
7.8 pts better
|
79.7%
10.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
22.7%
0.4 pts better
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 21.6% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-02 · Fire 2023-08-02
26 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2022-07-13 · Fire 2022-07-13
15 health deficiencies
Top issue: Resident Rights (6 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-02
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2026-01-01
F · Potential for more than minimal harm
2025-12-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-07
F · Potential for more than minimal harm
2025-12-02
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2026-01-01
F · Potential for more than minimal harm
2025-12-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-01
F · Potential for more than minimal harm
2024-11-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-12-11
F · Potential for more than minimal harm
2024-11-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-19
F · Potential for more than minimal harm
2024-11-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-11-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-14
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 2024-12-11
E · Potential for more than minimal harm
2024-11-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-14
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-14
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 2024-12-11
D · Potential for more than minimal harm
2024-11-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-11-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-14
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-28
D · Potential for more than minimal harm
2024-11-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-11
C · Minimal harm
2024-11-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-12
F · Potential for more than minimal harm
2023-08-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-29
F · Potential for more than minimal harm
2023-08-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-29
F · Potential for more than minimal harm
2023-08-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-29
F · Potential for more than minimal harm
2023-08-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-29
F · Potential for more than minimal harm
2023-08-02
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-08-29
F · Potential for more than minimal harm
2023-08-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-29
E · Potential for more than minimal harm
2023-08-02
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 2023-08-29
D · Potential for more than minimal harm
2023-08-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-08-02
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 2023-08-29
D · Potential for more than minimal harm
2023-08-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-08-02
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-08-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-08-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-29
F · Potential for more than minimal harm
2022-07-13
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-08-12
F · Potential for more than minimal harm
2022-07-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-12
F · Potential for more than minimal harm
2022-07-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-07-13
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 2022-08-12
E · Potential for more than minimal harm
2022-07-13
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-07-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-07-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-07-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-07-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-13
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-13
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-08-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-14
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 2026-02-02
D · Potential for more than minimal harm
2025-12-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-12-01
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-12-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-02-19
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-03-17
L · Immediate jeopardy
2024-11-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-17
J · Immediate jeopardy
2024-11-14
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-12-17
F · Potential for more than minimal harm
2024-11-14
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-14
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 2024-12-17
E · Potential for more than minimal harm
2024-11-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
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 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
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 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-14
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 2024-12-17
D · Potential for more than minimal harm
2024-11-14
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-12-17
G · Actual harm
2024-10-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-13
J · Immediate jeopardy
2024-08-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-01
G · Actual harm
2024-08-20
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 2024-10-08
G · Actual harm
2024-08-20
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 2024-09-10
F · Potential for more than minimal harm
2024-08-20
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 2024-09-10
D · Potential for more than minimal harm
2024-08-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-10
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 2024-08-09
D · Potential for more than minimal harm
2024-07-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-16
F555 · Resident Rights Deficiencies
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-16
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 2024-08-09
E · Potential for more than minimal harm
2024-07-01
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 2024-07-23
J · Immediate jeopardy
2024-06-19
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 2024-05-27
D · Potential for more than minimal harm
2024-06-19
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 2024-07-10
D · Potential for more than minimal harm
2024-06-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-04-23
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 2024-05-14
D · Potential for more than minimal harm
2024-04-23
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 2024-05-14
K · Immediate jeopardy
2024-03-04
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 2024-03-26
E · Potential for more than minimal harm
2024-03-04
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-03-26
D · Potential for more than minimal harm
2024-03-04
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 2024-03-26
K · Immediate jeopardy
2024-01-19
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 2024-02-09
E · Potential for more than minimal harm
2024-01-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-19
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 2024-02-09
D · Potential for more than minimal harm
2024-01-19
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 2024-02-09
F · Potential for more than minimal harm
2023-08-02
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 2023-08-29
D · Potential for more than minimal harm
2023-08-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-08-02
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 2023-08-29
D · Potential for more than minimal harm
2023-08-02
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-08-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-08-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-07-05
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 2023-07-30
D · Potential for more than minimal harm
2023-07-05
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 2023-07-30
D · Potential for more than minimal harm
2023-05-16
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 2023-06-12
D · Potential for more than minimal harm
2023-05-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-03-16
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 2023-03-31
D · Potential for more than minimal harm
2023-03-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-08
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 2023-03-30
D · Potential for more than minimal harm
2022-07-13
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 2022-08-12
D · Potential for more than minimal harm
2022-07-13
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-13
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 2022-08-12
Penalties and ownership
What sits behind the stars
$174,612
2024-10-17
Fine
Fine · fine $174,612
Fine
$0
2024-10-17
Payment Denial
Payment Denial · denial start 2024-11-15 · 43 days
43 day denial
$15,939
2024-06-04
Fine
Fine · fine $15,939
Fine
$40,072
2024-06-04
Fine
Fine · fine $40,072
Fine
$0
2024-06-04
Payment Denial
Payment Denial · denial start 2024-08-09 · 60 days
60 day denial
$8,989
2024-03-04
Fine
Fine · fine $8,989
Fine
$36,508
2024-01-19
Fine
Fine · fine $36,508
Fine
Ownership
Bedrock Hc Wi LLC
5% Or Greater Direct Ownership Interest · Organization
Chopp, Pnina
5% Or Greater Indirect Ownership Interest · Individual
Chopp, Martin
5% Or Greater Indirect Ownership Interest · Individual
Chopp, Solomon
5% Or Greater Indirect Ownership Interest · Individual
Freson, Raymond
Operational/Managerial Control · Individual
Opal Healthcare Wi LLC
Operational/Managerial Control · Organization
Ramanujam, Sandeep
Operational/Managerial Control · Individual
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5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Lake Mills Health Services
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2-star overall rating with 2-star inspections with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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