Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Dove Healthcare - Spooner during CMS and state inspections, most recent first.
Improper dish drying and steam table sanitation were observed in the kitchen. A surveyor saw plastic containers stacked while still moist, slotted plastic dinner plates stacked immediately after leaving the dish machine while still wet, and a clean steam table cover placed on a steam table that still contained water and had not been cleaned. Staff stated the steam tables were cleaned once daily and that the same water remained in them throughout the day, while the DM and DON acknowledged dishes should be completely dry and the steam table cover should not be placed on a dirty unit.
Infection control failures were identified when the facility did not test residents or staff with COVID-19 symptoms despite its policy requiring monitoring and testing of suspected cases, and multiple symptomatic residents and staff had no documented testing. Surveyors also observed a CNA emptying a catheter drainage bag without placing a barrier under the graduated cylinder and providing shower care for a resident on EBP without wearing PPE during the shower. The DON confirmed the expected practices for catheter care and PPE use.
Failure to notify provider of new toe skin breakdown. A resident with DM and other chronic conditions developed a new break in skin on the right great toe. Staff documented scant bleeding and inflammation, but survey review found no evidence that the new skin change was promptly assessed or reported to the on-call MD. RN stated the injury was new and that no one had informed her about it, while the DON stated new skin issues should be reported immediately to the next shift, physician on call, and DON.
Failure to provide timely ABN/NOMNC notices for two residents with Medicare Part A coverage ending before benefit days were exhausted. For one resident, the facility could not locate the ABN or NOMNC in paper form or EMR despite notes saying they were given. For another resident, the NOMNC was signed only 1 day before the last covered day instead of the required 2-day notice; the SW and DON confirmed the missing documentation and timing issue.
A resident with dementia and a BIMS of 13/15 was started on psychotropic meds without targeted behavior monitoring or a clear prior dx of anxiety or depression. Staff obtained new orders for Escitalopram and Lorazepam after a family request and an ER visit for syncope, while the record showed only limited anxious episodes before initiation. Afterward, the resident had dizziness, nausea, confusion, hallucinations, restlessness, and multiple unwitnessed falls, and surveyors found no behavior monitoring or rationale documented before the meds were started.
A resident with DM and other chronic conditions developed a new break in skin on the right great toe, but staff did not document a thorough assessment of the injury when it was first found. The chart showed intact skin on prior foot checks, then scant bleeding and inflammation at the toenail line, while the RN reported she was unaware of the injury, did not know who applied the bandage, and could not find documentation of an assessment.
Failure to Monitor Significant Weight Loss: A resident with dementia, DM, HTN, MDD, and dysphagia had weekly weights ordered, but multiple weekly weights were missed and the resident’s documented weight declined significantly over several months. Survey review found the resident was not identified on the dietary manager’s NAR reports, and charting did not show timely documentation addressing the weight loss or updated care plan interventions until later in the review period.
Failure to Provide Timely Toileting and Incontinence Care: A resident with dementia, urinary and bowel incontinence, and extensive ADL assistance needs was observed lying in bed for hours without staff providing toileting or incontinent care. Surveyors later found the resident with a urine-soaked brief, urine-soaked mattress, and deteriorated brief material on the floor and skin. Staff statements showed the resident was left in bed based on sleep habits, and peri care was not fully completed after the wet brief was changed and toileting was provided.
A hospice resident with severe cognitive impairment and total dependence on staff developed a pressure ulcer due to the facility's failure to provide appropriate support surfaces and timely interventions. Despite being at high risk for skin breakdown, the resident did not receive an alternating air mattress or Roho cushion until after a pressure injury developed. Interviews revealed a lack of communication and coordination among staff regarding the resident's care needs.
The facility's steam heated hot water system was not maintained properly, leading to fluctuating water temperatures that were often inadequate for resident use. Observations showed temperatures ranging from 80 to 100 degrees Fahrenheit, below the required levels. Residents and staff reported inconsistent water temperatures, and the Director of Maintenance acknowledged ongoing issues with the system, which was installed in the 1960s. Despite regular checks and adjustments, the system's performance remained inconsistent.
A resident with type 1 diabetes experienced unmanaged hypoglycemia and hyperglycemia due to the facility's failure to follow diabetic protocols. Staff did not administer glucagon or recheck blood glucose levels as required, nor did they notify the physician of these episodes. Interviews revealed that staff based insulin administration on the resident's preferences rather than medical guidelines, despite previous education on protocols.
A resident with type 1 diabetes experienced significant medication errors due to facility staff not following diabetic protocols. Staff administered glucagon outside prescribed parameters and allowed the resident to dictate insulin dosages, leading to incorrect administration. Interviews revealed staff prioritized resident preferences over physician orders, compromising the resident's health.
The facility did not maintain the required RN coverage of at least 8 consecutive hours a day, 7 days a week, affecting all 50 residents. On certain weekends, RN coverage was less than 8 hours, with specific dates showing only 4.5 hours of coverage and one day with no coverage at all. The DON and NHA confirmed the deficiency, acknowledging the lack of full coverage on these dates.
The facility failed to follow food safety standards, affecting 48 residents. Opened milk containers were not labeled with opening dates, and staff did not perform hand hygiene between glove changes while handling food. A staff member used contaminated gloves to handle various surfaces and ready-to-eat foods, contrary to facility policy and the Wisconsin Food Code. The DON confirmed that hand hygiene should be performed between glove changes.
The facility failed to maintain an effective infection prevention and control program, lacking a comprehensive water management plan to prevent Legionella transmission. Staff did not adhere to Enhanced Barrier Precautions, failing to wear appropriate PPE during high-contact care. Infection surveillance was inadequate, with poor tracking of symptoms and insufficient testing for influenza or RSV. The Infection Preventionist's limited presence led to communication gaps, contributing to the deficiencies.
The facility failed to implement its policies and procedures for screening employees for a history of abuse, neglect, or exploitation. Background checks for five out of eight staff members were either delayed or incomplete, potentially affecting all residents. The HR representative was unaware of the reasons for these deficiencies, and the Nursing Home Administrator acknowledged ongoing efforts to achieve compliance.
A resident, who is dependent on staff for care following a stroke, was repeatedly observed lying in bed uncovered and visible from the hallway, with the room door open and privacy curtain not pulled. Despite the presence of staff, no actions were taken to cover the resident or ensure privacy. The resident indicated discomfort with the situation, and the Director of Nursing acknowledged the dignity concern.
A resident with Alzheimer's and dementia had a stop sign barrier intervention to prevent other residents from entering her room. However, surveyors observed that the barrier was not consistently in place, and staff interviews revealed a lack of awareness and consistency in maintaining it. The DON confirmed the intervention was still active but acknowledged it might not have been moved during a room change.
A resident with multiple diagnoses, including hemiplegia and osteoarthritis, had a care plan that failed to reflect their preferred toileting method, which was less painful than other options. The CNA and DON were aware of the resident's preference, but it was not documented in the care plan.
A resident with multiple diagnoses requiring assistance with ADLs was left unattended for extended periods, resulting in unmet needs for meal assistance, repositioning, and incontinence care. Despite the care plan indicating the need for supervision during meals and regular repositioning, staff failed to provide the necessary support, as observed by surveyors. Interviews with staff confirmed a lack of adherence to care expectations.
A resident at high risk for falls did not have a pressure alarm on their wheelchair, despite it being a part of their care plan. Observations showed the resident without the alarm, and staff interviews revealed confusion about its necessity. The lack of consistent use of the pressure alarm indicates a failure to follow the care plan to prevent falls.
Two residents with indwelling Foley catheters received inadequate care, leading to potential complications and UTIs. One resident was hospitalized for a UTI and sepsis, with staff failing to follow proper infection control practices during catheter care. Another resident's catheter was changed monthly without clinical indications, contrary to CDC guidelines. The facility's policies on perineal care, hand hygiene, and catheter care were not followed, indicating a need for improved training and adherence to standards.
Two residents with gastrostomy tubes experienced deficiencies in their care, including improper management of feeding supplies and failure to check tube placement. Feeding bags were left open to air, and supplies were stored improperly, increasing contamination risk. An LPN did not use PPE as required, and the Director of Nursing confirmed these practices were against facility protocols.
The facility failed to provide written notifications to residents or their representatives regarding hospital transfers, including reasons for the transfers. This deficiency was identified for several residents with complex medical conditions, who were transferred without receiving the required written notices. The Nursing Home Administrator acknowledged the lack of compliance with this requirement.
Improper Dish Drying and Steam Table Sanitation
Penalty
Summary
Improper sanitation practices were observed in the kitchen during dishwashing and steam table handling. The facility policy for dishwashing states that all items are to be air dried in racks before storing, but on 07/22/25 the surveyor observed plastic containers stacked together in the clean area near the 3-compartment sink with visible moisture inside the outside container. The surveyor also observed slotted plastic dinner plates being stacked together immediately after coming out of the dish machine while several plates were still visibly wet. The surveyor further observed a clean cover for a portable steam table being placed onto the steam table while the unit still contained water from prior to breakfast and had not been cleaned. No pan was observed in the steam table when the clean cover was replaced. The facility policy regarding steam tables states to wash the top with warm soapy water and cloth, spray sanitizing solution, empty water, and wash all covers after each meal. During interview, staff stated the portable steam tables are cleaned once a day at the end of the day and once per week with Lime, and that the same water remains in them throughout the whole day. The Dietary Manager stated dishes should air dry completely before being put away and steam tables should at least be wiped down if visibly dirty and should have a pan inside if the lid is on. The DON agreed that dishes should be completely dry and that clean lids on dirty steam tables could have the potential for bacteria concerns.
Infection Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infections, including COVID-19. The facility policy stated that staff were to be alert to signs of COVID-19 and that the Infection Preventionist would monitor and track COVID-19 related information, including the number of residents and staff with signs, symptoms, suspected, or confirmed COVID-19. However, the Infection Preventionist stated she was not testing residents and staff for COVID-19 when the community transmission level was low and planned to begin testing later in the summer. The Vice President of Clinical Operations and the DON confirmed that resident and staff testing had not been completed since sometime in 04/2025 and acknowledged this was not the standard of practice. The resident and staff line lists reviewed by surveyors showed multiple residents and staff with symptoms such as fever, diarrhea, cough, nausea, vomiting, sore throat, and gastrointestinal complaints with no indication of testing. The facility also failed to follow its catheter care procedure for a resident with an indwelling catheter. The resident had diagnoses including renal insufficiency, neurogenic bladder, and a history of MDRO ESBL resistance, and the care plan included catheter care and monitoring intake and output. During observation, a CNA emptied the resident’s urinary drainage bag and placed the graduated cylinder directly on the floor and later on the bathroom sink counter without placing a barrier underneath, despite the facility policy requiring a barrier under the drainage bag and graduated cylinder. When interviewed, the CNA stated she was not aware of the facility policy or recent education on catheter care and the need to use a barrier. The DON stated the expectation was to place a barrier under the graduated cylinder, usually a paper towel. The facility also did not ensure proper infection control measures were followed during shower care for the same resident who was on Enhanced Barrier Precautions. Surveyors observed EBP signage and PPE supplies outside the resident’s room, but the CNA removed gown and gloves before leaving the room and then brought the resident to the shower room without wearing PPE during the shower process. The CNA later asked whether a gown should have been worn in the shower, and another CNA stated PPE should be worn during a shower for the resident. The DON confirmed that the expectation was to wear PPE during the shower for a resident under EBP.
Failure to Notify Provider of New Toe Skin Breakdown
Penalty
Summary
The facility failed to notify the physician on call of R40’s new break in skin on the right great toe. R40 was admitted with diagnoses including acute respiratory failure with hypoxia, type 2 diabetes mellitus, obstructive sleep apnea, venous insufficiency, morbid obesity, bilateral osteoarthritis of the hip, and prostatic hyperplasia. The care plan included diabetic nail care, and weekly diabetic foot checks documented intact skin on 07/07/25, 07/14/25, and 07/15/25, with dry feet and slight edema noted on 07/21/25 that was not new to the resident. On 07/22/25, the diabetic foot check documented scant bleeding to the right great toe with inflammation along the toenail line and no purulent drainage; the area could not be measured due to the location of the toenail and inflammation. The note stated the toe was cleansed with normal saline, covered with a band aid and gauze tube, the resident was added to weekly wound rounds, and an appointment was made for provider evaluation. Surveyor review found no documentation that staff notified the provider of the new skin change or assessed it when first identified. RN M stated the injury was new and that no one had informed her about it, and later reported she would notify the on-call doctor for a virtual assessment. DON B stated staff expectation was to report any new skin issue immediately to the next shift, physician on call, and DON, and to assess, measure, cleanse, document, and notify the on-call provider.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on staff interview and record review, the facility did not provide Advanced Beneficiary Notice (ABN) and/or Notice of Medicare Non-Coverage (NOMNC) appropriately for 2 of 3 residents reviewed whose Medicare Part A coverage was discontinued with benefit days remaining. One resident had a skilled Medicare A service episode that began on 03/19/25 with a last covered date of 04/19/25, and the facility/provider initiated discharge from Medicare A services before benefit days were exhausted. The SNF Beneficiary Protection Notification Review form indicated the ABN and NOMNC were marked as not found in paper form or EMR, despite handwritten notes stating they were given. Another resident had a skilled Medicare A service episode that began on 02/01/25 with a last covered date of 03/19/25, and the facility/provider initiated discharge from Medicare A services before benefit days were exhausted. The SNF Beneficiary Protection Notification Review form indicated both the ABN and NOMNC were provided, but the resident’s NOMNC was dated 03/18/25, which was only 1 day before the last covered day instead of the required 2-day notice. The SW stated that a NOMNC should be presented for signature a minimum of 2 days prior to the last covered day, and confirmed the document for this resident was signed 1 day prior. The SW and DON were unable to locate the ABN and NOMNC for the first resident.
Unnecessary psychotropic medications without adequate indication
Penalty
Summary
The facility did not ensure that 1 of 5 residents reviewed, R2, was free from unnecessary psychotropic medications and did not ensure adequate indication for use of those medications. R2 was admitted with diagnoses including dizziness and giddiness and dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. The most recent MDS showed a BIMS score of 13/15, indicating R2 was cognitively intact. Facility policy stated psychotropic medications require additional monitoring and individualized monitoring, including targeted behavior monitoring, but the record review found no targeted behavior monitoring in place before Lorazepam and Escitalopram were started. Before the psychotropic medications were initiated, the record showed no prior diagnosis of anxiety or depression. General behavior monitoring in the 30 days before the medications were started documented 4 episodes of anxiousness. The record also showed R2 was being treated for a UTI with Nitrofurantoin from 05/09/25 to 05/23/25. On 05/21/25, staff spoke with R2's daughter, who requested a mood stabilizer, but she was not the activated POA at that time. R2 was sent to the ER for loss of consciousness/syncope, and the next day staff contacted the hospital clinic manager and then received new orders from R2's physician for Escitalopram, Lorazepam, and a new diagnosis of depression with anxiety. The POA was signed and activated on 05/22/25. After the psychotropic medications were started, the record documented dizziness, nausea, confusion, hallucinations, restlessness, roaming, undressing, and repeated falls. Progress notes showed R2 felt dizzy and nauseated, later reported dizziness again, and at other times experienced hallucinations and confusion. Pharmacy recommended discontinuing PRN Lorazepam, but the provider instead changed it to scheduled nightly dosing, and later increased it to twice daily after increased anxiety and behaviors were reported. R2 continued to have confusion and unwitnessed falls, including ER transfers for fall-related pain and another fall with no new orders. Surveyor interviews with R2, CNA O, RN M, and DON B confirmed ongoing anxiety, confusion, falls, and that behavior monitoring should have been completed before starting the medication, while the surveyor located no behavior monitoring or rationale before the psychotropic medication use.
Failure to Assess and Document New Toe Skin Injury
Penalty
Summary
The facility did not provide appropriate skin assessment and treatment according to orders, resident preferences, and goals for one resident with diabetes and multiple chronic conditions, including acute respiratory failure with hypoxia, venous insufficiency, morbid obesity, bilateral hip osteoarthritis, and prostatic hyperplasia. The resident’s care plan included nursing nail care, and weekly diabetic foot checks documented intact skin on 07/07/25, 07/14/25, 07/15/25, and 07/21/25, with dry feet and slight edema noted on 07/21/25. On 07/22/25, the diabetic foot check documented scant bleeding on the right great toe with inflammation along the toenail line and stated the open area could not be measured because of the toenail placement and inflammation; the toe was cleansed, bandaged, and the resident was added to wound rounds and scheduled to see the provider. Survey review found no progress note documentation showing that staff assessed the new skin change on the right great toe. The resident told the surveyor the great right toe had a sore from the podiatrist cutting the toenail, and the surveyor observed a bandage and kerlix wrap on the toe. The RN told the surveyor she was not aware of the injury before that morning and that it was new, and she did not know when the bandage had been applied. The RN also stated she had not found documentation of an assessment in the chart and was unsure who placed the bandage or failed to report the finding. The DON stated staff were expected to thoroughly assess, measure, cleanse, document, and notify the on-call provider for a new skin issue, but the record and staff interviews did not show that this occurred when the toe injury was first identified.
Failure to Monitor Significant Weight Loss
Penalty
Summary
The facility did not ensure acceptable parameters of nutritional status to maintain a resident’s usual body weight. The resident was admitted with diagnoses including Alzheimer’s disease, dementia, type 2 diabetes mellitus, essential hypertension, major depressive disorder, and dysphagia. The resident’s MDS showed incontinence of urine and bowel, supervision assistance with eating, and substantial to maximal assistance with multiple activities of daily living. The care plan included set-up assistance for eating, consultation with RD, monitoring for significant weight loss, and weights as ordered. The resident had weekly weights ordered, but the record showed multiple missed weekly weights between January and July 2025. The weights documented showed a decline from 223.7 lbs to 204.7 lbs, and later to 200 lbs, reflecting significant weight loss. Survey review also found that the resident was not identified on the dietary manager’s Nutritional At Risk reports from January through July 2025, despite the weight changes documented in the chart. Progress notes showed varied meal intake, a trial of mechanical soft texture, and later a nutritional risk assessment noting dysphagia and recommending a sugar-free house supplement twice daily. However, survey review found no documentation addressing the resident’s weight loss and no updated care plan with new interventions until early July 2025. Interviews with the dietary manager and DON confirmed that the resident had not been captured on the NAR reports and that staff were unsure how the significant weight loss was missed.
Failure to Provide Timely Toileting and Incontinence Care
Penalty
Summary
The facility did not ensure activities of daily living for toileting and incontinence care were provided for a resident with Alzheimer's disease, dementia, type 2 diabetes mellitus, essential hypertension, major depressive disorder, and dysphagia. The resident's MDS showed urinary incontinence, frequent bowel incontinence, and substantial to maximal assistance needs for personal hygiene, showering/bathing, toileting, transferring, dressing, and footwear. The care plan included assistance needs for bed mobility, eating, dressing, toilet use, and transfer. On 07/22/25, surveyors observed the resident in bed for extended periods with the room door closed, including early morning, late morning, and early afternoon. A CNA entered the room at one point and asked if the resident wanted to get up for breakfast, but the resident declined and was left in bed. The CNA later told surveyors the resident was a late sleeper and usually got up around 1:00 PM to 2:00 PM, and that the CNA would get the resident up soon. Surveyors continued to observe the resident lying in bed without seeing staff provide incontinent care or offer toileting during the day. Later that afternoon, surveyors observed the resident lying partly off the bed with the fall alarm sounding and then saw two CNAs assist the resident. The resident was found with a urine-soaked brief, urine-soaked mattress, and visible flakes from the deteriorated brief on the floor, skin, and mattress. One CNA stated the resident had been in bed all day and had been up all night. The DON stated staff should check on the resident every 2 to 3 hours and offer toileting or incontinent care, and also stated the expectation was for CNAs to clean the whole peri care area front and back. However, a CNA later acknowledged not returning again to provide cares, and another CNA stated peri care was not completed to the resident's front area after the wet brief was changed and toileting was provided.
Failure to Prevent Pressure Ulcers in Hospice Resident
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident who was on hospice and nearing the end of life. The resident, who had severe cognitive impairment and was totally dependent on staff for transfers, toileting, repositioning, and personal hygiene, was admitted without skin issues but was at risk for skin breakdown. Despite this risk, the facility did not provide alternate support surfaces when skin issues were noted, and no new interventions were put into place when the resident's condition declined. The resident's care plan included interventions such as conducting weekly full-body skin inspections, providing a pressure reduction mattress and wheelchair cushion, and repositioning the resident. However, the facility did not implement these interventions effectively. The resident developed an open area on the left buttock, which was initially treated but later progressed to an unstageable pressure injury with black eschar and drainage. The facility's failure to provide an alternating air mattress or a Roho cushion earlier contributed to the development of the pressure injury. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's care needs. The Director of Nursing and the wound nurse were unaware of the resident's need for an alternating air mattress and a Roho cushion until after the pressure injury developed. The facility's inaction and lack of timely interventions led to the resident developing a pressure injury that was not adequately addressed, contributing to the deficiency identified by the surveyor.
Inconsistent Hot Water Temperatures in Facility
Penalty
Summary
The facility failed to maintain its steam heated hot water system in a safe operating condition, resulting in fluctuating water temperatures that were often inadequate for resident use. The facility's Water Management Program Policy and Procedure requires that hot water temperatures be maintained between 140 to 150 degrees Fahrenheit in holding tanks, with safe bathing temperatures at 100 degrees Fahrenheit. However, observations and interviews revealed that the water temperatures in resident rooms and showers were frequently below the required levels, with temperatures ranging from 80 to 100 degrees Fahrenheit during the surveyor's checks. Interviews with residents and staff confirmed the inconsistency in water temperatures. Residents reported that the water was sometimes not hot enough for bathing, and staff noted that it often took a long time for the water to reach a warm temperature. The Director of Maintenance acknowledged that the facility's hot water system, installed in the 1960s, had ongoing issues, including a sticking steam valve and a mixing valve that required frequent adjustments. Despite these known issues, there had been no attempts to repair the system. The Director of Maintenance indicated that the system was checked regularly, and adjustments were made as needed. However, the water temperatures did not remain consistent throughout the day, as evidenced by the surveyor's findings. The Nursing Home Administrator was informed of the issues, and it was noted that the water temperature problems would be reported to the corporate office for further action.
Failure to Follow Diabetic Protocols in Resident Care
Penalty
Summary
The facility failed to provide appropriate diabetic care and treatment for a resident with type 1 diabetes, resulting in multiple instances of unmanaged hypoglycemia and hyperglycemia. The staff did not adhere to the established diabetic protocol, which required administering glucagon for blood glucose levels below 54 mg/dL and rechecking blood glucose within 15 minutes after intervention. Additionally, the staff failed to notify the resident's physician of these episodes, which is a critical step in managing the resident's condition. The resident, who has a complex medical history including type 1 diabetes, chronic kidney disease, and vascular dementia, experienced numerous episodes of low blood glucose levels. Despite the facility's policy outlining specific steps for managing hypoglycemia, the staff repeatedly did not administer glucagon when necessary, did not recheck blood glucose levels in a timely manner, and failed to monitor and document vital signs and symptoms. These omissions were observed over several months, indicating a pattern of non-compliance with the facility's diabetic management protocol. Interviews with the resident and staff revealed further issues in the management of the resident's diabetes. The resident expressed concerns about receiving too much insulin and experiencing frequent low blood sugar episodes. The LPN interviewed admitted to not following the diabetic protocol strictly and based insulin administration on the resident's preferences rather than medical guidelines. The DON acknowledged that despite previous education on diabetic protocols, staff continued to deviate from the expected procedures. The endocrinologist emphasized the importance of following the protocol and being notified of blood glucose levels below 70 mg/dL, highlighting the critical nature of these deficiencies.
Significant Medication Errors in Diabetic Management
Penalty
Summary
The facility failed to ensure that a resident with type 1 diabetes mellitus was free from significant medication errors. The resident, who also has multiple health complications including chronic kidney disease and vascular dementia, experienced numerous instances where the facility staff did not follow the diabetic protocol for hypoglycemic episodes. The staff administered glucagon outside of the prescribed blood glucose parameters and failed to administer it when the resident's blood glucose levels were critically low. Additionally, the staff did not document the reasoning for these actions or notify the physician as required by the facility's policy. The resident's medical records revealed multiple instances where insulin was administered based on the resident's request rather than following physician orders. The staff allowed the resident to dictate the amount of insulin administered, despite the absence of a physician order permitting this. This led to incorrect dosages being given, which were not aligned with the prescribed treatment plan. The facility's staff also failed to document the number of insulin units administered and did not follow the protocol for treating low blood glucose levels, such as administering glucagon or notifying the physician. Interviews with the facility's staff, including the Director of Nursing and nursing staff, indicated a lack of adherence to the diabetic protocol. The staff admitted to administering insulin based on the resident's preferences rather than following the physician's orders. The endocrinologist confirmed that the facility staff should adhere to the diabetic protocol and expressed concerns about the resident making their own decisions regarding insulin usage. The failure to follow the protocol and physician orders resulted in significant medication errors, compromising the resident's health and safety.
Insufficient RN Coverage in Facility
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, which has the potential to affect all 50 residents residing in the facility. This deficiency was identified through a record review conducted by the surveyor on May 22, 2024, which revealed that on certain weekends in May, specifically on the 4th, 5th, 18th, and 19th, RN coverage was less than the required 8 hours. On May 4th, 5th, and 18th, only 4.5 hours were covered by an RN, and on May 19th, there was no RN coverage at all. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA), it was confirmed that the procedure for covering RN shifts involves calling available RNs, and if no one is available, the DON or the Infection Preventionist would cover the hours. However, on the specified dates, the DON acknowledged that they did come in but did not work the full 8 hours, and the NHA confirmed the lack of coverage on May 19th and insufficient hours on the other dates.
Food Safety and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, which had the potential to affect 48 of 50 residents who received nourishment from the kitchen. During an inspection, it was observed that opened milk containers in the refrigerator were not labeled with the date they were opened, contrary to the facility's policy requiring all commercial products to be labeled with the date of initial opening. The Dietary Manager was unable to provide the opening dates for the milk containers when questioned by the surveyor. Additionally, there were multiple instances of improper hand hygiene practices during food service. A staff member, identified as [NAME] M, was observed using single-use gloves to handle various surfaces and ready-to-eat foods without performing hand hygiene between glove changes. This included touching ladles, food covers, and bread with contaminated gloves, and then serving food to residents. Despite the facility's policy and the Wisconsin Food Code requiring hand hygiene between glove changes, both [NAME] M and the Dietary Manager incorrectly believed that hand hygiene was not necessary if the staff remained in the hot service area. The Director of Nursing later confirmed that hand hygiene should be performed between glove changes.
Inadequate Infection Control and Water Management in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which had the potential to affect all 49 residents. The facility lacked a comprehensive water management plan to prevent the transmission of Legionella, as evidenced by the absence of a detailed flow system diagram, audits, and documentation of hot spots, stagnation, and dead-leg areas. The Maintenance Director admitted to not documenting audits or flushing procedures, indicating a significant gap in the facility's water management practices. Staff members did not adhere to Enhanced Barrier Precautions (EBP) protocols, as observed in multiple instances. Certified Nursing Assistants (CNAs) and a Licensed Practical Nurse (LPN) failed to wear appropriate Personal Protective Equipment (PPE) while providing high-contact care to residents on EBP. In one case, CNAs entered a resident's room without gowns or gloves, despite a sign indicating EBP requirements. Similarly, an LPN did not wear full PPE while performing tube feeding for a resident on EBP, acknowledging the oversight only after being questioned by the surveyor. The facility's infection surveillance was inadequate, as it did not track the type and onset of symptoms for staff and resident infections. During a COVID-19 outbreak, the Infection Preventionist (IP) did not document symptom onset or provide alternative testing for influenza or RSV when COVID-19 tests were negative. The IP was only present at the facility three times a week, leading to communication gaps and instances where staff returned to work prematurely after illness. The lack of proper documentation and communication regarding infection control measures further contributed to the facility's deficiencies.
Failure to Implement Employee Background Check Policies
Penalty
Summary
The facility did not implement its policies and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property. This deficiency was identified for five out of eight staff members reviewed. The facility's policy required background checks to be completed before employment and repeated every four years. However, several staff members had delayed or incomplete background checks. For instance, a Dietary Aide was hired before the background check was completed, and a Housekeeper who had resided in Minnesota did not have a background check from that state. Additionally, an Environmental Services Director and two Certified Nursing Assistants had delayed background checks, with one CNA's check being overdue by several months. The Human Resources representative, HR N, who was interviewed, stated that these employees were hired before they started working in their position and did not know the reasons for the delays or omissions. The Nursing Home Administrator confirmed that the facility was aware of the non-compliance issue and had been working on achieving 100% compliance since HR N was hired. This lack of adherence to the facility's own policies and procedures had the potential to affect all residents by not ensuring that staff members were properly vetted for any history of abuse, neglect, or exploitation.
Resident Privacy and Dignity Not Maintained
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident, identified as R43, who was observed multiple times lying in bed uncovered, wearing only an incontinent brief, and visible from the hallway. R43, who was admitted following a stroke and is dependent on staff for care, was observed by the surveyor on several occasions with the room door open and the privacy curtain not pulled, exposing the resident to passersby. Despite the presence of staff members, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), no actions were taken to cover the resident or close the privacy curtain. The surveyor noted that R43 was unable to speak but could communicate by nodding. When asked if they were comfortable with the lack of privacy, R43 indicated no by shaking their head. The Director of Nursing (DON) acknowledged the dignity concern when informed of the observations. The facility's inaction in ensuring the resident's privacy and dignity, despite clear indications of discomfort from the resident, constitutes a deficiency in care.
Failure to Implement Safety Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive individualized safety care plan for a resident diagnosed with Alzheimer's disease, dementia, and cognitive communication deficit. The resident, identified as R34, experienced an incident where another male resident entered her room and urinated. As a result, a stop sign barrier was introduced as an intervention to prevent other residents from wandering into her room. However, observations by the surveyor on multiple occasions revealed that the stop sign barrier was not consistently in place across the doorway as intended. This lack of implementation was noted despite the care plan specifying the use of the stop sign barrier when the resident was in her room, particularly at night. Interviews with facility staff, including CNAs and LPNs, indicated a lack of awareness and consistency in maintaining the stop sign barrier. Some staff members were unsure of the barrier's location, while others noted that the resident had been known to remove it. The Director of Nursing confirmed that the intervention was still active but acknowledged that the barrier might not have been moved during a room change. This inconsistency in following the care plan led to the deficiency identified by the surveyor.
Failure to Update Toileting Care Plan for Resident
Penalty
Summary
The facility failed to review and revise the comprehensive toileting care plan for a resident, identified as R7, who was always incontinent of bowel and bladder. R7 was admitted with multiple diagnoses, including hemiplegia and hemiparesis following a cerebral infarction, osteoarthritis, anxiety disorder, hip pain, and constipation. The care plan, dated March 27, 2024, did not reflect R7's preferred method of toileting, which was to use Depends briefs while lying on their left side, as other methods like the commode or bedpan were too painful. This preference was not documented in the care plan, despite being known to the staff through experience. The surveyor observed that the CNA was aware of R7's toileting preference from experience rather than documented instructions. Interviews with the CNA, R7, and the Director of Nursing confirmed that the current toileting method was the least painful for R7 and had been in place for some time. The Director of Nursing acknowledged that the care plan should have been updated to reflect R7's preferences. Additionally, therapy services confirmed that R7 had attempted therapy for other toileting methods but chose to stop all therapies and pursue palliative care.
Failure to Provide Required ADL Assistance
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) such as meal set-up, repositioning, and incontinence care were provided for a resident, identified as R21. R21 was admitted with multiple diagnoses, including alcohol-induced persisting dementia and aphasia following cerebral infarction, and was assessed to require assistance with various ADLs. The care plan specified that R21 needed supervision for eating, assistance with personal hygiene, dressing, and was dependent on staff for transferring and toileting. Despite these needs, observations revealed that R21 was left unattended for extended periods without receiving necessary assistance. On the morning of the survey, a CNA delivered R21's breakfast tray but did not assist with eating or repositioning. The resident was observed lying in bed, unable to reach the food, and the tray remained untouched for several hours. Throughout the morning and early afternoon, surveyors noted that staff did not enter R21's room to provide assistance, despite the resident's apparent inability to eat independently. When staff did enter the room, they focused on R21's roommate and did not check on R21 or provide the required assistance. Interviews with staff, including a CNA and the Director of Nursing (DON), revealed a lack of adherence to the care plan and facility expectations. The DON confirmed that R21 should have been repositioned and provided incontinence care every two hours and required supervision during meals to prevent aspiration. However, the surveyor's observations indicated that these care needs were not met, as staff failed to provide the necessary assistance and supervision for R21's meals and other ADLs.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent falls and injury for a resident identified as R40. R40 was admitted with multiple diagnoses, including unspecified mood disorder, cognitive communication deficit, and major depressive disorder, and was assessed as a high fall risk. The care plan for R40 included the use of a pressure alarm on the wheelchair to prevent falls. However, during multiple observations by the surveyor, R40 was seen sitting in a wheelchair without the pressure alarm in place, which was a critical intervention to alert staff if R40 attempted to rise from the wheelchair. Interviews with facility staff, including a CNA, LPN, DON, and OT, revealed a lack of clarity and communication regarding the implementation of the pressure alarm intervention. The CNA was unsure if the alarm was necessary, while the LPN and DON confirmed that the alarm should have been in place. The OT explained that the alarm was added due to R40's impulsiveness and risk of falls, especially in open areas. Despite these acknowledgments, the pressure alarm was not consistently used, indicating a failure in following the established care plan to prevent falls for R40.
Deficient Catheter Care and Infection Control Practices
Penalty
Summary
The facility failed to provide appropriate catheter care for residents with indwelling Foley catheters, leading to potential complications and urinary tract infections (UTIs). For Resident 43, the staff did not follow proper infection control practices during catheter care. The surveyor observed a Certified Nursing Assistant (CNA) using the same washcloth for different areas of the perineal region and catheter, which is against the facility's policy. Additionally, the CNA did not perform hand hygiene between glove changes, which is a critical step in preventing infections. Resident 43 had a history of UTIs and was recently hospitalized for a UTI and sepsis, indicating a serious lapse in care. Resident 29's care also did not align with professional standards. The facility had an open-ended order to change the resident's Foley catheter on a routine monthly basis without clinical indications, contrary to the Centers for Disease Control and Prevention (CDC) guidelines. The Director of Nursing (DON) was unaware that the standard of practice had changed and believed that regular changes were still required. This misunderstanding led to unnecessary catheter changes, which could increase the risk of infection and other complications. The facility's policies on perineal care, hand hygiene, and catheter care were not adequately followed, contributing to the deficiencies observed. The staff's lack of adherence to these policies, particularly in hand hygiene and the sequence of perineal care, highlights a significant gap in training and awareness. The DON acknowledged the errors and the need to update practices to align with current standards, but the deficiencies observed indicate a need for immediate attention to prevent further harm to residents.
Deficiencies in Feeding Tube Management and Infection Control
Penalty
Summary
The facility failed to ensure proper treatment and services for residents with feeding tubes, as observed in two cases. Resident R32, who has multiple medical conditions including type 1 diabetes, chronic kidney disease, and dysphagia, was found to have a gastrostomy tube feeding setup that was not properly managed. The feeding bag was left open to air, and the tubing was not labeled with the date it was opened. Additionally, the LPN did not check the placement of the G-tube before administering feedings, which is against the facility's protocol. In the case of R32, the LPN was observed not using personal protective equipment (PPE) as required, and the feeding supplies were improperly stored on the bathroom counter, increasing the risk of contamination. The Director of Nursing confirmed that the supplies should be stored outside the bathroom and that the LPN should have used PPE. The LPN also failed to recap the tubing end properly, leaving it exposed to air, which was not in line with the facility's infection control practices. For resident R43, who also has a gastrostomy tube due to conditions like cerebral infarction and dysphagia, similar issues were noted. The feeding supplies were left uncovered on the bathroom counter, and the feeding bag was left open to air. Although the LPN administered medications and feedings correctly, the improper storage of supplies and open feeding bag were consistent with the deficiencies observed in R32's care.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide timely written notification to residents or their representatives regarding transfers to the hospital, including the reasons for such transfers, as required by regulations. This deficiency was identified during a survey that reviewed the cases of five residents who were hospitalized. For instance, one resident with spastic hemiplegia and aphasia following a stroke was transferred to the hospital multiple times without their legal guardian receiving written notice of the transfers. Similarly, another resident with cerebral infarction and related conditions was hospitalized, and their representative was only informed verbally, not in writing. The survey also revealed that a resident with multiple complex medical conditions, including an amputation and chronic kidney disease, was hospitalized several times without receiving written explanations for the transfers. Additionally, a resident with congestive heart failure was transferred to the hospital without a written notice that included the reason for the transfer. The facility's Nursing Home Administrator acknowledged that they had not been providing written notices of discharge or transfer, which is a requirement. This oversight had the potential to affect all 50 residents in the facility.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 65 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Spooner
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shell Lake Health Care Center | 10.9 mi | ★★★★★ | 9 | 0 |
| Care And Rehab - Cumberland | 21.3 mi | ★★★★★ | 14 | 0 |
| Dove Healthcare - Rice Lake | 22.7 mi | ★★★★★ | 15 | 0 |
| Heritage Lakeside | 23 mi | ★★★★★ | 15 | 1 |
| Hayward Health Services | 24 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.