Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Johnson Memorial Hospital & Home during CMS and state inspections, most recent first.
A facility failed to ensure that all licensed nurses were trained and competent in insulin administration, leading to a resident receiving the wrong type of insulin. The error was reported, and the resident was monitored without adverse effects. The DON admitted to a lack of formal training records and audits, despite policy requirements for ongoing education.
The facility did not meet its own assessed staffing requirements for RNs, LPNs/TMAs, and NAs on multiple weekend shifts, with documented shortfalls in nursing assistant hours and inconsistencies in LPN/TMA coverage. The DON confirmed that the facility assessment was outdated and that required staffing levels were not maintained as specified.
The facility did not submit complete and accurate direct care staffing data to CMS, as required, due to failures in tracking and reporting hours worked by contracted and on-call RNs. The DON confirmed that some RN hours were omitted from the PBJ report, and the payroll coordinator did not verify the accuracy of submitted data. No policy was in place for PBJ reporting.
The facility did not ensure that the infection preventionist maintained complete and accurate surveillance of employee illness, as multiple department heads failed to report required data and return-to-work dates, and illness tracking logs lacked individual staff identifiers, hindering effective oversight and exposure tracking.
Facility staff failed to label insulin pens with required open and discard dates for multiple residents, as observed during medication administration and storage checks. Nursing staff and the DON confirmed that facility policy and manufacturer guidelines require such labeling, but several insulin pens in use lacked this information.
A resident with severe cognitive impairment eloped from the facility without staff knowledge, despite wearing a WanderGuard bracelet. The door failed to lock, and the alarm did not sound. The care plan was not updated to include new interventions to prevent future elopements, and staff were unaware of the incident.
A resident with diabetes was mistakenly given the wrong type of insulin due to a failure in following medication administration protocols. The facility lacked a formal process to verify nurse competency in insulin administration, relying on on-the-job training without documented audits or competency checks.
A resident with significant cognitive and physical impairments experienced a fall that was not properly assessed or monitored by staff. Despite displaying and reporting severe pain for several hours after the fall, the resident did not receive a comprehensive pain assessment, pain relief, or timely physician notification. Inadequate communication and documentation among staff led to a delay in identifying a hip fracture, resulting in delayed medical attention and pain management.
The facility failed to notify the county (SMHA) when a resident had a new onset of mental illness since admission. The resident's diagnoses included delusional disorders, paranoid schizophrenia, obsessive-compulsive disorder, depression, and anxiety. The medical record lacked any indication that the SMHA had been notified of these new diagnoses. Interviews revealed no process in place to ensure notification, despite the facility's policy requiring it.
The facility failed to revise the care plan for a resident with peripheral edema and cardiomyopathy. Despite significant edema and weight gain, the care plan lacked interventions for managing edema. Observations showed the resident with 4+ edema, often seated with feet on the floor, and not using support stockings or a foot stool. Interviews confirmed non-compliance with recommended interventions, and the DON acknowledged the care plan should have been updated.
Insulin Administration Training Deficiency
Penalty
Summary
The facility failed to ensure that all licensed nurses, including both regular and agency staff, were appropriately trained and deemed competent in administering insulin according to facility policy and manufacturer's instructions. This deficiency was identified through observation, interviews, and document reviews, revealing that none of the 14 nurses who administered or had the potential to administer insulin had documented training or competency assessments. The incident involved a resident who was mistakenly given 36 units of Fiasp, a short-acting insulin, instead of the prescribed 36 units of Basaglar, a long-acting insulin. The error was reported to the resident's primary provider, and the resident was monitored for any adverse effects, though none were reported. The director of nursing (DON) acknowledged the lack of a formal checklist or accessible records to verify that insulin administration training or competencies had been completed. Training was reportedly conducted on the job by nurse managers, but no audits were performed to ensure compliance. The facility's in-service education policy required continuing education and training to meet regulatory and licensing requirements, with initial and annual training based on departmental needs. However, the absence of documented training and competency assessments for insulin administration highlighted a significant gap in the facility's adherence to its own policies and procedures.
Failure to Maintain Required Staffing Levels per Facility Assessment
Penalty
Summary
The facility failed to implement and maintain a facility-wide assessment that accurately determined and provided the necessary staffing resources to care for residents competently during both regular operations and emergencies. Document review showed that the facility's assessment identified specific staffing requirements for RNs, LPNs/TMAs, and NAs for each shift on both weekdays and weekends. However, a review of six sampled weekend dates revealed that the actual staffing hours for nursing assistants (NAs) consistently fell short of the required hours as outlined in the facility assessment. Additionally, there were discrepancies in LPN/TMA hours on some shifts, and night shift NA hours were also below the required levels on multiple occasions. During an interview, the DON acknowledged that the staffing needs had been determined by a previous interim administrator and confirmed that the facility assessment required review and revision, as the staffing hours should be consistent across weekdays and weekends. The DON also agreed that the required staffing hours identified in the facility assessment were not met on the sampled weekend shifts. No additional policy related to staffing was provided by the facility at the end of the survey.
Failure to Accurately Report Direct Care Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for Quarter 4 of 2024, as required. Review of the Payroll Based Journal (PBJ) report revealed that excessively low weekend staffing had triggered a concern. Further examination of staff schedules and timecards showed that a contracted RN worked a 12-hour shift on 7/6/24 but did not clock in using the facility's system, resulting in those hours not being included in the PBJ report. Additionally, an on-call hospital RN worked an 8-hour shift on 8/17/24, but there was uncertainty about whether those hours were properly recorded and allocated to the nursing home. The DON confirmed the omission of the contracted RN's hours and was unsure about the process for on-call hospital staff. The payroll coordinator stated he submitted PBJ hours without running verification reports and only checked for the presence of an RN each day. The facility did not have a policy on PBJ reporting.
Failure to Ensure Effective Infection Surveillance and Reporting
Penalty
Summary
The facility failed to ensure proper oversight by the infection preventionist (IP) in managing the infection prevention and control program, specifically regarding the tracking and documentation of employee illness. Over a three-month period, multiple department heads did not consistently report required surveillance data, resulting in incomplete records for 33 out of 60 staff and missing return-to-work dates for numerous staff who called in sick. The surveillance logs only included department information and not individual staff identifiers, making it impossible to determine specific areas of exposure or to track potential transmission to residents. Interviews revealed that the IP was aware of the ongoing issue with department heads not submitting information timely and had raised these concerns in interdisciplinary team meetings. The administrator was also aware of the problem and had discussed it in QAPI meetings, expecting the IP to retrain department heads if necessary. The facility's policy required supervisors to report detailed illness information, but the policy did not specify that the IP should identify individual staff, limiting the ability to provide comprehensive oversight and exposure tracking.
Failure to Label Insulin Pens with Open and Discard Dates
Penalty
Summary
Surveyors observed that facility staff failed to properly label insulin pens with both open and discard dates for six residents who were prescribed insulin. During medication administration, registered nurses were seen removing insulin pens from medication cupboards and administering insulin without ensuring that the pens were labeled according to manufacturer instructions. In several instances, insulin pens in active use lacked either an open date, a discard date, or both. This was confirmed through direct observation of medication administration and inspection of medication storage areas, where multiple insulin pens for different residents were found without the required labeling. Interviews with nursing staff and the director of nursing revealed that the facility's protocol required staff to label insulin pens with both open and discard dates once removed from refrigeration, in accordance with manufacturer guidelines. Staff acknowledged that insulin pens not properly dated should be discarded and replaced, and that it was not appropriate to administer insulin without verifying expiration dates. Review of the facility's Medication Administration Protocol further confirmed the expectation that medications, including insulin, be labeled with open and discard dates and checked for expiration prior to administration.
Failure to Revise Care Plan After Resident Elopement
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced an actual elopement event. The resident, who had severe cognitive impairment due to Alzheimer's dementia, delirium, and disorientation, was observed exiting the building without staff knowledge. Although the resident was wearing a WanderGuard bracelet, the door did not lock, and the alarm did not sound as expected. The resident was found approximately 10 feet from the door after another resident notified the staff. Despite the incident, the care plan was not updated to include new interventions to prevent future elopements. Interviews with facility staff revealed a lack of awareness regarding the resident's elopement. A registered nurse and a nursing assistant both reported measures they typically take to monitor the resident, such as keeping doors closed and offering diversions, but neither was aware of the actual elopement event. The director of nursing acknowledged that the care plan should have been updated to reflect the elopement and implement new preventive measures, but it was not done. The facility's policy requires care plan revisions when a resident's condition changes, which was not adhered to in this case.
Insulin Administration Error Due to Lack of Competency Verification
Penalty
Summary
The facility failed to administer insulin according to physician orders and manufacturer instructions for a resident who was administered the wrong insulin. The incident involved a resident with a medical history of Alzheimer's, dementia with psychotic disturbance, depression, and diabetes. The resident was scheduled to receive 36 units of Basaglar, a long-acting insulin, but was mistakenly given 36 units of Fiasp, a short-acting insulin. The error was identified by the staff nurse during documentation, who then reported the incident to the resident's primary provider. The provider instructed the staff to monitor the resident's blood sugar levels. The resident did not experience any side effects from the incorrect insulin administration. The facility's Medication Administration Protocol policy requires nursing staff to follow medication rights, including verifying the right medication, dose, route, time, and ensuring the medication has not expired. However, the facility lacked a formal checklist to ensure licensed nurses were deemed competent in insulin administration upon hire or annually. The Director of Nursing acknowledged that there were no accessible records of employee training or competencies related to insulin administration, and training was conducted on the job by nurse managers. Although in-service training sessions on insulin administration were held, the facility did not conduct audits to ensure compliance with the protocol.
Failure to Assess, Monitor, and Treat Pain After Resident Fall
Penalty
Summary
A resident with diagnoses including parkinsonism, dementia, and primary progressive aphasia experienced a fall that was not witnessed by staff. The resident was found on the floor and initially assessed by staff, who noted a red area on the right lower back but did not identify or document any pain at that time. The resident was dependent on staff for all activities of daily living and was at high risk for falls due to balance problems and poor communication abilities. Following the fall, there was no further monitoring or assessment for injuries for nearly 14 hours. During the night following the fall, the resident began to display and report severe pain, including vocal complaints and facial grimacing, particularly during personal care activities. Despite these clear indicators of pain, the night shift LPN did not reassess the resident, provide pain relief, or notify the physician. Communication between staff was inadequate, as the night shift nursing assistant was not informed of the fall, and the LPN failed to document or report the incident and the resident's pain to the oncoming shift. The resident's pain was not comprehensively assessed, and no additional pain medication was administered beyond the scheduled dose of Tylenol prior to the fall. It was not until the following morning that the day shift LPN was notified of the resident's pain and conducted an assessment, which led to physician notification and subsequent hospital transfer. The resident was diagnosed with a right hip fracture requiring surgical repair. The facility's policies on pain management, fall assessment, and notification of changes in condition were not followed, as evidenced by the lack of timely assessment, documentation, and communication after the fall and during the period when the resident was experiencing significant pain.
Failure to Notify SMHA of New Mental Illness Diagnoses
Penalty
Summary
The facility failed to notify the county (designated state mental health authority (SMHA)) when a resident had a new onset of mental illness since admission. The resident's annual Minimum Data Set (MDS) assessment identified diagnoses of delusional disorders, paranoid schizophrenia, obsessive-compulsive disorder, depression, and anxiety. The pre-admission screen (PAS) initially identified that the resident did not have a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders (DSM). However, the resident's current diagnosis list showed new diagnoses of schizophrenia and obsessive-compulsive disorder, and a new delusional disorder. The medical record lacked any indication that the SMHA had been notified of these new diagnoses. Interviews with the social service designee and the administrator revealed that there was no process in place to ensure notification of new mental illness diagnoses, despite the facility's policy requiring the social worker or director of nursing to contact Senior Linkage for a new PASARR referral.
Failure to Revise Care Plan for Resident with Peripheral Edema
Penalty
Summary
The facility failed to revise the care plan for a resident with peripheral edema and a diagnosis of cardiomyopathy. The resident was admitted with multiple diagnoses including diabetes, an implantable cardiac defibrillator, and hypertensive heart disease. Despite observations and documentation indicating significant edema and weight gain potentially related to fluid retention, the care plan did not include interventions for managing edema. The resident's psychosocial note indicated she had agreed to try some interventions for her leg edema, but these were not reflected in the care plan. Observations over several days showed the resident with 4+ edema in her feet and ankles, often seated with her feet on the floor and not using support stockings or a foot stool, which she reportedly refused to use due to fear of falling. Interviews with nursing staff confirmed the resident's non-compliance with recommended interventions such as leg elevation and wearing compression stockings. The Director of Nursing acknowledged that the care plan did not address the problem of peripheral edema, a known side effect of cardiomyopathy, and confirmed that it should have been updated to include monitoring and interventions for edema and weight changes. The facility's policy required care plans to be individualized, comprehensive, and reviewed monthly, with revisions made as needed to address current problems, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dawson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madison Healthcare Services | 8.4 mi | ★★★★★ | 10 | 0 |
| Clarkfield Care Center | 15.7 mi | ★★★★★ | 5 | 0 |
| Luther Haven | 17.3 mi | ★★★★★ | 2 | 0 |
| Sylvan Court | 18.7 mi | ★★★★★ | 4 | 0 |
| Appleton Area Health | 18.7 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.