Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
3D
4E
2F
Potential for minimal harm
0A
0B
0C
February 25, 2026Standard inspection · 4 citations
- F
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.
Inspectors wroteBased on observations and record review, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional practice. This had the potential to affect stock medication that could be used for all residents. Currently there are 15 out of 31 residents (R) needing medication requiring temperature control for proper storage. (R3, R4, R5, R11, R12, R13, R19, R20, R21, R24, R27, R28, R33, R40, R41)Routine monitoring of temperature levels of medication refrigerators in both medication rooms is not consistently being done. There were 3 narcotics, 39 insulin pens, 5 other injectable types, 161 vaccines, 10 suppositories, and 3 ophthalmic suspensions that are temperature sensitive found in medication storage. Narcotic medication was not destroyed promptly and per WI Administrative Code 132.65 (6)(c). [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections Laundry Aide failed to follow infection prevention procedures while handling clean linen. This has the potential to affect all 31 residents (R) in the facility. Registered Nurse (RN) failed to clean tip of insulin pen prior to attaching a needle and administering insulin to 1 out of 3 residents observed for insulin administration. (R4)RN failed to clean the glucometer after use, prior to putting away, during 2 out of 3 resident observations of diabetic care. (R4, R20)CNA did not clean the non-mechanical lift between patient use. This affected 2 of 4 residents observed during a non-mechanical lift. [...]
- E
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on interviews and record review, the facility did not ensure residents with limited range of motion (ROM) received services to maintain or prevent further reduction in ROM for 6 out of 6 residents (R) receiving restorative services. R3, R4, R5, R8, R15, and R23Facility has only one trained restorative aide and no back up aide if the restorative aide does not work. Residents do not receive consistent restorative services. This is evidenced by:The facility policy, titled Restorative Nursing Program, dated 2/2026 states:Policy: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level.3. Nursing personnel are trained in basic, or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review, the facility did not ensure that each resident received adequate assistance devices to prevent accidents or injury and promote safe transfers for 1 resident of 4 residents (R8) reviewed for accident prevention in a sample of 31. The facility did not utilize gait belt during a toileting transfer to enhance R8's function or safety and placed R8 at risk of injury.
November 27, 2024Standard inspection · 0 citations
October 18, 2023Standard inspection · 5 citations
- E
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteExample 4 R3 was admitted to the facility on [DATE], and had diagnoses that include paranoid schizophrenia, anxiety disorder, major depressive disorder, dementia, hypertensive heart disease, and type 2 diabetes. R3's Minimum Data Set (MDS) assessment indicated that R3 had a Brief Interview for Mental Status (BIMS) of 05 which indicated R3 has severe impairment. On 10/17/23, Surveyor reviewed R3's care plan and restorative documentation, which identifies the following individualized restorative program. ROM Group exercises 5 times a week with a goal is strength for cares done Monday, Tuesday, Wednesday, Thursday, and Friday. On 10/17/23, Surveyor reviewed R3's care plan and restorative documentation from 9/28/23 through 10/17/23, which identifies the restorative program missing documentation indicating the program was not completed. Noted 9 missed opportunities out of 14. [...]
- E
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.
Inspectors wroteBased on observation, interview and record review, the facility did not ensure prior to the installation or use of bed rails, attempted to use alternative devices, assess the resident for risk of entrapment from bed rails, obtain consent with the resident or resident representative for review of risks and benefits of bed rails for 8 of 8 residents (R) R12, R13, R16, R27, R3, R4, R14, R22) observed with side rails/enabler bars during the survey process. The facility failed to attempt alternatives prior to installation of grab bars and failed to obtain informed signed consent of risk and benefit for grab bars with the resident or resident representative for R12, R13, R16, R27, R3, R4, R14, and R22. This is evidenced by: On 10/18/23 at 10:06 AM, Surveyor received and reviewed side rail policy entitled: Restraint-free environment which includes .8. [...]
- E
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation and interview, the facility did not inspect for compatibility of bed frames, mattresses, and bed rails for 8 of 8 residents (R) R12, R13, R16, R27, R3, R4, R14, R22. The facility failed to conduct as part of their regular maintenance program, inspection of all bed frames, mattresses, and bed rails for potential risk of entrapment on 8 of 8 residents (R) R12, R13, R16, R27, R3, R4, R14, R22 observed with side rails/enabler bars up during the survey process. This is evidenced by: Based on the Food and Drug Administration (FDA) documents entitled Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated March 10, 2006, Practice Hospital Bed Safety dated February 2013, and Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: [...]
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 of 8 employees reviewed for background checks. The facility allowed a Certified Nursing Assistant (CNA) G to work with residents on 01/14/23 and 01/15/23 before background check was received. Background check was received on 01/20/23. This is evidenced by: The facility policy, entitled Abuse, Neglect, Mistreatment, Exploitation and Misappropriation of Resident Property, dated November 2022, states: 1. Screening components . Abuse Policy Requirements: it is the policy of Dove Healthcare to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background checks. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interviews, the facility did not ensure the resident received care consistent with professional standards of practice for pressure injury care for 1 of 1 residents (R) 14. R14 had a deep tissue injury; weekly wound assessments with description of wound and measurements were not completed.
Fire safety inspections
6 fire safety citations on file: 2 on February 25, 2026, 3 on November 27, 2024, 1 on October 18, 2023.
Every fire safety citation6 citations
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 25, 2026 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · February 25, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 27, 2024 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 27, 2024 · Corrected (the home has a date of correction)
- C
Provide a written emergency evacuation plan.
K 711 · November 27, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 18, 2023 · Corrected (the home has a date of correction)