Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Hope Health And Rehab during CMS and state inspections, most recent first.
A resident with a history of fractures and severe osteoporosis experienced a significant increase in pain and reported hearing a 'pop' in the leg during a transfer. Despite these symptoms, staff did not perform or document required assessments or ongoing monitoring of the affected limb, and pain management was inconsistently provided. The lack of timely assessment and documentation led to a delayed diagnosis of a displaced femur fracture, which was only identified after an x-ray and subsequent hospital transfer.
A resident with multiple comorbidities experienced a significant change in condition, including abdominal pain, distension, and altered mental status. Facility staff failed to document all symptoms, perform thorough RN assessments, or notify the physician of critical changes in vital signs and lab results. The lack of ongoing monitoring and timely intervention led to the resident's continued decline and eventual death from hyperkalemia after transfer to the hospital.
Surveyors found that food was not stored, prepared, or served according to professional standards, including dust accumulation above food prep areas, improperly labeled and stored food items, and food stored directly on the floor. These issues had the potential to affect nearly all residents in the facility.
Surveyors found that the facility did not provide an ongoing program of activities to meet the interests and well-being of all residents, particularly on weekends and evenings. Multiple residents, including those with both intact and impaired cognition, reported a lack of activities during these times, and attendance records confirmed no participation in activities on several weekends. The activity calendars showed minimal or no scheduled programming for evenings and weekends, and staff interviews confirmed the absence of regular activities during these periods.
A resident with type 2 diabetes experienced multiple episodes of hypoglycemia, with blood glucose readings below the ordered threshold, but the physician or NP was not notified as required by facility policy and physician orders. Staff and DON confirmed that notification should have occurred for each incident, but documentation and interviews revealed this did not happen.
A resident with diabetes, peripheral vascular disease, and osteomyelitis did not receive routine diabetic foot checks as required, due to the absence of a facility policy, lack of physician orders and care plan interventions for foot inspections until days after admission, and failure to document or perform foot checks in the TAR as confirmed by LPN and DON interviews.
A resident with moderate cognitive impairment and multiple medical conditions was allowed to independently leave the facility, cross a street, and smoke in an unsafe area without proper supervision or guidance. The resident did not consistently return smoking materials to staff, disposed of cigarette butts unsafely, and staff lacked training and clear procedures for smoking assessments and monitoring. Facility policy was not effectively implemented, resulting in unsafe smoking practices.
A resident with type 2 diabetes and moderate cognitive impairment experienced repeated episodes of low blood sugar in the mornings and was not consistently provided with a routine nightly snack as required by facility policy. Staff interviews confirmed that snacks should be offered and documented, but records showed inconsistent provision and no documentation of refusal.
A CNA failed to follow standard infection control practices while providing pericare to a resident by placing contaminated wash cloths back into the basin and handling the bedside cabinet and powder with contaminated gloves, without performing hand hygiene or changing gloves, contrary to facility policy and standard precautions.
A resident who had previously received pneumococcal vaccines was not offered the recommended follow-up dose of PCV20 or PCV21, as required by facility policy and CDC guidelines. Record review and staff interviews confirmed that the resident was not up to date and had not been offered the immunization, indicating a failure to follow established vaccination protocols.
The facility failed to adhere to food safety standards, including improper storage of Mighty Shakes, presence of dust in the air exchange system above the stove hood, circulation of a dented can, and undated food items in the freezer. These deficiencies indicate a lack of adherence to food safety protocols, potentially affecting all 34 residents.
A resident with severe cognitive impairment voiced concerns about the condition of the wall in her room, which had large white patched areas and small holes. Despite raising the issue multiple times, the wall remained unrepaired for several months. Facility staff acknowledged the problem but cited delays due to the roommate's aversion to paint smell.
Failure to Assess and Monitor Resident After Change in Condition
Penalty
Summary
The facility failed to ensure that a resident received necessary care and services in accordance with professional standards of practice following a change in condition. The resident, who had a history of multiple fractures, end-stage renal disease, and severe osteoporosis, experienced a significant increase in pain and reported hearing a 'pop' in the left leg during a transfer. Despite these symptoms and the resident's complaints of severe pain, there was no documented assessment or ongoing monitoring of the affected limb as required by the resident's care plan. Specifically, there was no documentation of assessments for edema, bruising, skin temperature changes, loss of sensation, or pulses distal to the suspected fracture site. Nursing staff, including a CNA and two RNs, were present during the incident and were aware of the resident's complaints of pain. However, the night shift RN did not perform an assessment after the resident expressed pain during movement. The day shift RN was notified of the pain upon the resident's return from dialysis and contacted the nurse practitioner, who ordered an x-ray. Despite the resident's continued complaints of significant pain, there was a lack of documented reassessment and monitoring throughout the shifts, and pain management was not consistently provided according to the resident's needs. The facility did not have a change in condition policy and procedure, and staff interviews confirmed that a full assessment, including vital signs and evaluation of the injury site, should have been completed and documented. The lack of timely and thorough assessment, documentation, and ongoing monitoring resulted in a delay in identifying a complete oblique fracture of the left femur with displacement, which was only confirmed after an x-ray was eventually performed and the resident was sent to the hospital for further evaluation.
Failure to Assess and Respond to Change in Condition Results in Resident Death
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a significant change in condition. The resident, who had a history of type 2 diabetes mellitus, morbid obesity, polyneuropathy, hypotension, COPD, and sleep apnea, presented with symptoms including abdominal pain, nausea, distension, and changes in mental status. Despite these symptoms, staff did not document all of the resident's symptoms in the medical record, nor did they complete a thorough and ongoing RN assessment related to the change in condition. There were multiple instances where staff failed to perform a full set of vital signs, abdominal assessments, or pain assessments, even when the resident expressed severe discomfort and abnormal findings were present. The facility's own policy required prompt identification and effective action in response to changes in condition, including in-depth RN assessments and immediate notification of the attending practitioner. However, documentation shows that these steps were not consistently followed. For example, when the resident reported severe abdominal pain and other symptoms, staff administered medications but did not perform or document comprehensive assessments or notify the physician in a timely manner. Critical lab results indicating hyperkalemia and abnormal kidney function were not acted upon with the urgency required, and vital signs that warranted immediate physician notification were not communicated as per standard protocols. Additionally, there was a lack of ongoing monitoring and documentation of the resident's deteriorating condition. Interviews with facility leadership and staff confirmed that expected assessments and documentation were not completed, and that the medical record did not accurately reflect the resident's symptoms or the care provided. The failure to document and respond appropriately to the resident's change in condition, including not notifying the physician of critical changes and not providing continued monitoring, contributed to the resident's continued decline. The resident was eventually transferred to the hospital, where he was found to be pulseless and nonbreathing and subsequently expired due to a critical potassium level.
Removal Plan
- LPN R's employment was terminated.
- Vitals were taken on all residents to ensure no change in condition or need for additional assessment.
- Educational in-services on change in condition were provided for all clinical staff.
- Interviewed all residents and [NAME] of Attorney regarding comfort with cares and facility responsiveness to clinical needs to ensure the facility continues to meet the resident needs to their satisfaction.
- DON B performed chart review for all residents to ensure all changes in condition noted were accompanied by follow-up assessments and proper notification.
- DON B organized a skills fair for nursing to ensure competence in assessments, evaluations, nursing skills, and clinical judgement.
- Management team revamped morning meeting process with additional audits and accountability on 24 hour board.
- Continue audits and education on Stop and Watch program for entire staff. DON B will continue to provide scenarios.
Food Storage and Preparation Safety Deficiencies
Penalty
Summary
Surveyors identified several failures in the facility's food storage, preparation, and service practices that did not meet professional standards for food safety. During observation, a layer of dust was found on the stove hood, specifically on the sprinkler pipes and grease trap directly above the burners and food preparation area, creating a risk of dust falling into open food. Additionally, food items such as an opened bag of vanilla wafers were found in the dry storage area without proper labeling, sealing, or dating, contrary to facility policy requiring all food removed from original packaging to be labeled with the name and date. The Dietary Manager confirmed uncertainty about when the wafers were opened and acknowledged the lack of compliance with storage procedures. Further, a box of potatoes was observed sitting directly on the floor in the dry food storage area, which is against facility policy that requires all food to be kept off the floor and protected from contamination. The Dietary Manager acknowledged this issue and removed the potatoes from the floor. These deficiencies were observed to have the potential to affect 26 of 27 residents in the facility.
Lack of Weekend and Evening Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This deficiency was identified through observation, interviews, and record review, affecting one sampled resident and five supplemental residents. The activity calendars from December 2024 through March 2025 showed a lack of scheduled activities on Saturdays and Sundays, and minimal or unspecified activities during evenings. The calendars often listed only one-on-one visits with the activity assistant, with no group activities or specific programming for weekends and evenings. Additionally, the facility did not have a policy for activity programming. Multiple residents, both cognitively intact and severely impaired, voiced concerns during a Resident Council meeting about the lack of activities on evenings and weekends. Residents reported that the absence of activities made their days long and unengaging, particularly on weekends. Activity attendance records confirmed that these residents had no documented participation in activities on several consecutive Saturdays and Sundays. Residents also expressed specific interests, such as attending church services on Sundays and having music programs or community plays on Saturdays, which were not being met. Interviews with the Activity Director and Assistant Nursing Home Administrator revealed that there were generally no activities scheduled on Saturdays, and only occasional one-on-one or group activities on Sunday afternoons, depending on the availability of a part-time aide. The Activity Director acknowledged the lack of weekend and evening activities and indicated that music programs might resume in the future. The Assistant Nursing Home Administrator confirmed that activity staff should be offering activities during these times if residents requested them, but this was not occurring.
Failure to Notify Physician of Repeated Low Blood Sugar Events
Penalty
Summary
The facility failed to immediately notify and consult with a resident's physician when there was a significant change in condition for one resident with type 2 diabetes mellitus who was receiving insulin therapy. The resident experienced multiple episodes of low blood sugar (below the ordered parameter of 70 mg/dL), as documented in the Medication Administration Record, with values as low as 48 mg/dL on several mornings. Despite physician orders requiring notification if blood glucose was less than 70, there was no evidence that the physician or nurse practitioner was notified for each incident. Progress notes also lacked documentation of physician notification for several of these low blood sugar events. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was to notify the physician or nurse practitioner for blood sugars below 70, regardless of the resident's hospice status. However, the Director of Nursing acknowledged that the required notifications were not made for each low blood sugar occurrence. The facility's own policy and staff statements supported the need for immediate notification, but this was not consistently followed, resulting in a deficiency.
Failure to Provide Routine Diabetic Foot Checks
Penalty
Summary
A deficiency was identified when a resident with type 2 diabetes mellitus, peripheral vascular disease, and acute osteomyelitis of the left ankle and foot was not provided routine diabetic foot checks as required by professional standards of practice. The resident was dependent on staff for lower extremity care, including dressing and footwear, and had moderate cognitive impairment. Despite the resident's medical conditions and care needs, there was no policy in place for diabetic foot checks, and neither the physician orders nor the care plan included daily foot inspections until several days after admission. Interviews with nursing staff and the Director of Nursing revealed that foot checks for diabetic residents are expected to be documented in the Treatment Administration Record (TAR). However, review of the resident's TAR confirmed that foot checks were not listed or documented prior to the addition of the order and care plan intervention. Staff acknowledged that if foot checks are not documented in the TAR, they are not completed, resulting in the resident not receiving the required daily foot assessments.
Failure to Provide Adequate Supervision and Safe Smoking Practices
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and multiple medical diagnoses, including sepsis, blood clots, tremor, and alcohol dependence, was not provided adequate supervision to prevent accidents while smoking. The resident was observed independently leaving the facility in a wheelchair, wearing only gripper socks, and crossing a street to smoke. During this time, the resident navigated around moving vehicles, smoked in the street, and disposed of cigarette butts by putting them out with his fingers and placing the remnants in his jacket pocket. The resident reported that he was not given guidance on safe smoking practices and that staff had previously accompanied him to the same location, which was not considered safe by facility staff. The facility's smoking policy prohibits smoking on the property and requires residents to go off-premises to smoke, with specific procedures for signing out and returning smoking materials to staff. However, the resident did not consistently return smoking materials, sometimes keeping cigarettes and a lighter in his room. Staff interviews revealed a lack of training on smoking assessments and unclear procedures for monitoring and retrieving smoking materials. The social worker who completed the resident's smoking assessment had never done one before and had not received training. The assessment did not address all relevant safety concerns, such as the resident's ability to safely navigate the environment or dispose of cigarette materials. Further, there was no designated receptacle for cigarette disposal, and staff were uncertain about proper procedures for safe smoking off-premises. The resident's actions, including smoking in the street, improper disposal of cigarette butts, and failure to return smoking materials, were not adequately supervised or addressed by staff. Facility leadership acknowledged that the observed behaviors were unsafe and not in line with policy, but there was no evidence of consistent staff training or clear protocols to ensure resident safety during smoking activities.
Failure to Provide Routine Nightly Snack to Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide a suitable, nourishing snack to a resident with type 2 diabetes who required routine nightly snacks to help manage blood sugar levels. The resident, who had moderate cognitive impairment and was on a controlled carbohydrate diet with scheduled insulin administration, experienced multiple episodes of low blood sugar (below 70) in the mornings, as documented in the Medication Administration Record. Despite facility policy requiring bedtime snacks for residents unless contraindicated, documentation showed inconsistent provision and recording of snacks, with only a few instances noted and no documentation of resident refusal. Interviews with staff, including a registered nurse, CNA, and the DON, confirmed that snacks should be offered nightly to diabetic residents and that documentation of snack provision or refusal is required. However, review of the records revealed a lack of consistent documentation and no evidence that the resident was routinely offered or received a nightly snack, despite ongoing low blood sugar readings. The DON acknowledged that the resident should have been receiving a nightly snack and that there was no documentation of refusal.
Infection Control Breach During Pericare
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) failed to follow standard infection control practices during pericare for a resident. The CNA set up a wash basin with water and two wash cloths, used one wash cloth to perform frontal pericare, and then placed the contaminated wash cloth back into the basin. The CNA then used the second wash cloth to rinse the resident, placed it into the same basin, and proceeded to dry the resident. Without removing gloves or performing hand hygiene, the CNA touched the bedside cabinet drawer, removed a bottle of powder, applied it to the resident's groin, and returned the powder to the drawer, all while wearing the same contaminated gloves. During interviews, both the CNA and the Director of Nursing (DON) acknowledged that the wash cloths and gloves were contaminated after pericare and should not have been handled in the manner observed. The facility's policy on standard precautions requires hand hygiene before and after resident contact, after touching contaminated items, and after glove removal, which was not followed in this instance. The actions observed were in direct violation of the facility's infection prevention and control program, as outlined in their policy.
Failure to Offer Required Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident was offered a pneumococcal immunization in accordance with its own policy and current CDC recommendations. Specifically, the facility's policy required that all residents be educated about and offered pneumococcal vaccination upon admission and annually, with documentation of consent or declination. For one resident, there was no documentation that the recommended dose of PCV20 or PCV21 was offered, despite the resident having previously received Prevnar 13 and Pneumovax 23, and being due for an additional dose based on CDC guidelines. During an interview, the Infection Preventionist and Director of Nursing confirmed that the resident was not up to date with pneumococcal vaccinations and had not been offered the required dose. The Director of Nursing acknowledged that the vaccination should have been offered according to current guidance. This lack of action was identified through both record review and staff interviews, demonstrating a failure to follow established immunization protocols for the resident.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Surveyors observed several deficiencies, including Mighty Shakes stored in the refrigerator beyond the manufacturer's recommended 14-day usage period after thawing. The dietary manager and other staff were unaware of this recommendation, and the shakes had been in the refrigerator for 15 days without a thaw date. Additionally, hairlike dust was observed moving in the air exchange system above the stove hood, posing a risk of contamination to open food being prepared for resident meals. The dietary manager acknowledged the need for cleaning, and staff admitted the potential for dust to fall into the food. Further observations revealed a dented can of mandarin oranges in circulation, contrary to the facility's policy of removing dented cans from storage. Additionally, a bag of tator tots in the freezer was found without a use-by or opened date, and staff were unsure when it had been opened. These actions and inactions indicate a lack of adherence to food safety protocols, potentially affecting the health and safety of all 34 residents in the facility.
Failure to Maintain a Homelike Environment for Resident
Penalty
Summary
The facility did not ensure that each resident had a safe, clean, comfortable, and homelike environment, as evidenced by the condition of the wall in one resident's room. Resident R31, who has severe cognitive impairment with a BIMS score of 7 out of 15, voiced concerns about the wall in her room needing repair and paint. The surveyor observed large white patched areas and small holes on the tan-painted wall alongside R31's bed. R31 expressed that her walls at home did not look like this and that she had communicated her concerns to the facility staff multiple times since her admission. Despite these complaints, the wall remained in the same condition for several months. Maintenance Man G acknowledged that R31 had raised this issue during a resident council meeting and confirmed that it was on his list of tasks to complete. However, the repairs had not been made. Social Worker H also confirmed that R31 had brought up the issue during Care Plan Conferences, but the wall had not been painted yet. The Director of Nursing (DON B) was aware of the concern and mentioned that the project had been delayed because R31's roommate did not like the smell of paint. Despite this, DON B agreed that the wall should be painted to ensure R31's comfort and a homelike environment.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lomira
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avina Of Mayville | 9 mi | ★★★★★ | 12 | 0 |
| Edenbrook Of Fond Du Lac | 12.7 mi | ★★★★★ | 0 | 0 |
| Harbor Haven Health & Rehabilitation | 13 mi | ★★★★★ | 0 | 0 |
| St Francis Home | 13.1 mi | ★★★★★ | 12 | 0 |
| Avina On Division | 13.2 mi | ★★★★★ | 11 | 1 |
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