Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Whispering Creek during CMS and state inspections, most recent first.
The facility failed to submit complete and accurate PBJ staffing data to CMS because the report showed no licensed nursing coverage 24 hours/day on several shifts, even though schedules, timecards, and agency invoices showed licensed nurses were scheduled and paid for all covered shifts. An LPN stated a nurse served as charge nurse every shift, and the DON said she verified licensed nurse coverage. The administrator could not explain the discrepancy and stated an agency used in 2025 had not been added to the PBJ database.
The facility did not accurately submit weekend staffing data to CMS, resulting in a report of excessively low weekend staffing. Although actual staffing levels, including agency staff, were adequate, delays in obtaining agency staffing hours led to inaccurate PBJ data submission. No policy on PBJ submission was provided.
A resident with multiple chronic conditions, including atrial fibrillation and venous hypertension, was receiving warfarin as ordered by a physician, but the MDS assessment failed to indicate anticoagulant use. The DON and MDS coordinator confirmed the omission was an error, and a policy on MDS coding was not provided upon request.
A deficiency was cited for not ensuring an area was free from accident hazards and for failing to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient monitoring or hazard identification in the affected area.
The facility failed to submit accurate staffing data to CMS for a quarter in 2024, as the PBJ report indicated a lack of 24-hour licensed nursing coverage on six dates. However, reviews of schedules and timecards confirmed that licensed nurses were scheduled and paid for all shifts. The administrator was unable to identify the error source due to data formatting issues.
PBJ Staffing Data Not Submitted Accurately
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS through the PBJ system based on payroll and other verifiable and auditable data for Quarter 1, 2026. The PBJ Staffing Data Report triggered because it showed a failure to have licensed nursing coverage 24 hours per day on four infraction dates. However, record review of nursing staff schedules and daily staffing postings showed licensed nurses had been scheduled for 24 hours per day on each of those dates. Timecard sheets and/or agency invoices for the five employed nurses and one agency nurse covering the 12 shifts were reviewed and showed the scheduled nurses were paid for the shifts worked. During interviews, an LPN stated a nurse worked in the charge nurse capacity every shift, either an LPN or an RN. The administrator stated the facility scheduled one licensed nurse each shift and verified all shifts were covered, but could not explain the discrepancy. He later stated the person who uploaded the data had not been informed the facility had started using a particular agency in 2025 and had not added those agency nurses to the database. The DON stated she did the nursing schedules and verified a licensed nurse was scheduled as the charge nurse for each shift.
Failure to Accurately Submit Weekend Staffing Data to CMS
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS for Quarter 2, 2025, as required by federal regulations. The CMS payroll-based journal (PBJ) staffing data report indicated excessively low weekend staffing, which was not consistent with the facility's actual staffing levels. During interviews, the DON stated uncertainty about the low staffing trigger and confirmed that staff, including agency staff, were always present on weekends. The administrator, responsible for PBJ data submission, acknowledged a possible delay in receiving agency staffing hours, which may have led to the inaccurate data submission. Review of the facility's master nursing staff schedule and time card reports confirmed that there was no actual low weekend staffing during the reviewed period. The facility did not provide a policy on PBJ submission.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure that a resident's status was accurately identified on the Minimum Data Set (MDS) assessment. Specifically, a resident with diagnoses including peripheral vascular disease, chronic atrial fibrillation, edema, and chronic venous hypertension with ulcers and inflammation was receiving warfarin, an anticoagulant, as documented in physician orders. However, the quarterly MDS assessment did not indicate that the resident was receiving anticoagulant medication, despite other medications being correctly documented. The director of nursing confirmed that the MDS was coded incorrectly, and the MDS coordinator acknowledged that the omission was an oversight, as the resident had consistently been on warfarin during the assessment period. A policy on MDS coding was requested but not provided.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring within the facility. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision of the area in question. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate and complete staffing data to the Centers for Medicare and Medicaid Services (CMS) for Quarter 2, 2024. The Payroll-Based Journal (PBJ) Staffing Data Report indicated that the facility did not have licensed nursing coverage 24 hours a day on six specific dates. However, upon review of the nursing staff schedules and timecard sheets, it was confirmed that licensed nurses were scheduled and paid for working all shifts on those dates. Interviews with the nursing staff scheduler and the director of nursing verified that the facility maintained 24-hour licensed nurse coverage. The administrator was informed of the discrepancies in the PBJ Staffing Data Report and acknowledged that the staffing file was automatically uploaded to CMS. The administrator was unable to identify the source of the error due to the formatting of the data and confirmed that the facility did not use agency nurses. The facility's policy on reporting direct care staffing information, revised in August 2022, stated that staffing data should be reported electronically to CMS in a uniform format and based on verifiable information such as payroll records. Despite this policy, the facility's submission to CMS was inaccurate, leading to the deficiency finding.
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What surveyors actually found near you
We read the 84 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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 Janesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeshore Rehabilitation Center Llc | 9.9 mi | ★★★★★ | 0 | 0 |
| Oaklawn Care & Rehabilitation Center | 14.1 mi | ★★★★★ | 2 | 0 |
| Laurels Peak Care & Rehabilitation Center | 14.9 mi | ★★★★★ | 19 | 0 |
| Pathstone Living | 16.1 mi | ★★★★★ | 25 | 0 |
| Hillcrest Care & Rehabilitation Center | 16.9 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.