Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Oconto Health And Rehab Center during CMS and state inspections, most recent first.
A resident with intact cognition and multiple medical conditions reported that a CNA told them they could not be assisted out of bed into a wheelchair if they only wanted to be up for a short period, and this concern was documented as a grievance and reviewed by the DON. The same resident also disclosed giving a tumbler as a gift to the CNA, despite knowing gifts to staff were not allowed, and the CNA ultimately accepted the gift after initially refusing. Although the facility’s abuse, neglect, and exploitation policy required timely reporting of all alleged violations to the State Agency, the NHA and DON acknowledged that these allegations of abuse and exploitation were not reported as required.
A resident with intact cognition and multiple medical conditions reported that a CNA told them they could not get out of bed if they only wanted to be up in a wheelchair for a short period, and also reported having given a tumbler as a gift to the same CNA. The DON documented the grievance as the resident changing their mind about getting up and confirmed that the CNA initially refused but ultimately accepted the gift before returning it. However, the facility did not remove the CNA from resident care during the inquiry, nor did it interview other residents or staff to determine whether similar incidents or additional gift exchanges had occurred, and leadership later acknowledged the investigations were not sufficiently thorough.
Surveyors found that staff did not consistently clean or document cleaning of CPAP/BiPAP/AVAP equipment as ordered and per facility policy for three cognitively intact residents using respiratory support devices. One resident with obstructive sleep apnea and paraplegia had a daily AVAP mask cleaning order, but the treatment record lacked the cleaning order on a key date, and the resident reported mask cleaning was not done and later developed facial cellulitis. Another resident with obesity and obstructive sleep apnea had weekly CPAP cleaning orders but reported the mask was washed only once since admission, and the treatment record showed missed cleanings marked with a code requiring nursing notes that were not present. A third resident with acute and chronic respiratory failure had a daily BiPAP mask cleaning order, was unsure if cleaning occurred, and had at least one day without documented cleaning. An LPN stated nurses were responsible for cleaning and documenting, and the DON confirmed the expected daily mask and weekly tubing cleaning and acknowledged missing documentation.
A resident with facial cellulitis and intact cognition was prescribed oral clindamycin TID after an ER visit, but the facility failed to administer five ordered doses because the medication was not available from the pharmacy and was not in contingency stock. The MAR documented three missed doses on one day and two the next, with the first dose given later that second day. The physician was not notified of the missed doses. During this time, the resident’s facial cellulitis became more painful, leading to repeated hospital transfers where an MRSA cheek abscess with preseptal cellulitis was diagnosed and treated with irrigation, debridement, IV antibiotics, wound packing, and additional oral antibiotics.
Excessive lint buildup was observed in two dryer lint traps during a surveyor tour of the laundry room. One dryer had lint covering most of the bottom of the trap and about one inch high, while the other had lint about one-half inch high across part of the trap. The NHA confirmed the buildup did not appear to reflect daily cleaning, and the posted cleaning log showed an outdated last entry; a separate sheet later provided by the NHA listed twice-daily cleaning.
A resident used a CPAP machine, but the facility did not have physician orders for CPAP use or for cleaning and maintaining the equipment when the resident was admitted. The resident’s discharge summary did not include CPAP orders, the care plan initially only reflected RA, and the MAR/TAR had no CPAP-related orders. The resident was observed using the CPAP, stated staff did not clean the mask, tubing, or machine, and the DON confirmed the facility had set up the machine before admission even though the orders and diagnosis were not yet in the chart.
Failure to Obtain and Administer Ordered Pneumococcal Vaccines: Three residents who had consented to vaccination did not receive the ordered pneumococcal vaccine. One resident with moderately impaired cognition, one with CHF, ESRD, DM, and COPD, and one with severe cognitive impairment and an activated POAHC all had records showing consent for available vaccines, but Prevnar 20 was not administered. For one resident, no order for Prevnar 20 was obtained, and the NHA and DON reported the vaccines were delayed because the orders were submitted incorrectly and there was miscommunication with the pharmacy.
Missed COVID-19 Vaccine Order and Education for a Resident: A resident with intact cognition, COPD, diabetes with neuropathy, and other chronic conditions signed consent for COVID-19 vaccination and had a provider order to receive the vaccine, but the facility did not process the order or administer the vaccine. Survey review found no documentation that the resident received education on the risks and benefits, and the NHA confirmed the order was missed despite vaccine supply being available.
A resident with a history of dementia and other conditions experienced a worsening skin condition in the groin area, but the facility failed to notify the physician of this change. Despite documentation of care interventions, the lack of communication with the physician was a deficiency in the facility's protocol.
A resident's grievance regarding cleanliness, roommate issues, and shower frequency was not properly documented or resolved by the facility. The resident's guardian reported these concerns, but the facility failed to communicate the investigation's findings or any corrective actions taken. Despite some improvements, the guardian was not informed of interventions to prevent future issues.
A resident with a history of stroke and other conditions reported that a CNA twisted their wrist, causing pain. The incident was reported to staff and the resident's POAHC, but the facility failed to report the allegation to the State Agency or law enforcement as required by their policy. Interviews revealed that staff did not recall or act on the report, leading to a deficiency in reporting the abuse allegation.
A resident reported an allegation of physical abuse by a CNA, which was also communicated to the resident's POAHC and facility staff. However, the facility failed to conduct a thorough investigation as required by their policy, including obtaining statements from involved parties and documenting the incident. The NHA and DON were unaware of the allegation, indicating a deficiency in the facility's response to abuse reports.
Two residents received personal care from an unqualified Hospitality Aide (HA) who was not trained or certified to perform such tasks. The HA assisted with showering, feeding, and transferring, which was outside their job scope. The facility's administration was unaware of these actions.
A resident with an indwelling catheter and wounds did not receive proper infection control measures as CNAs and an RN failed to wear gowns and perform hand hygiene during care. The facility's policy on Enhanced Barrier Precautions was not followed, and gowns were not available near the resident's room. Staff interviews confirmed the oversight.
A resident with moderately impaired cognition refused multiple medications over several days, but the facility failed to notify the resident's physician and corporate Guardian as required by their policy. The medications included those for heart health, hypertension, OCD, depression, and diabetes. The resident's Guardian was unaware of these refusals, and the Director of Nursing acknowledged that staff should have contacted the physician after three refusals.
Two residents in an LTC facility experienced deficiencies in nutritional and hydration care. One resident, with multiple diagnoses, did not have their diet order updated despite a recommendation, leading to weight loss. Another resident, at risk for dehydration, had inconsistent fluid intake documentation. The facility failed to adhere to its policies on nutritional management and hydration monitoring.
Two residents in the facility did not receive their prescribed medications correctly. One resident did not receive calcium 200 mg due to unavailability, and the LPN failed to notify the physician. Another resident received the wrong form of Seroquel XR 50 mg, as the LPN administered a non-extended release version from contingency stock without physician consultation. These actions were against the facility's Medication Administration Policy.
A resident with impaired cognition and a corporate guardian was unable to set up a petty cash fund or RFMS account due to the facility's requirement for direct deposit information, which the guardian could not provide. The facility returned checks sent for the resident, and interviews revealed a lack of process for managing petty cash accounts without direct deposit. The resident expressed a desire for financial independence, but the facility did not accommodate this need.
A resident with a history of diabetes, right hand amputation, and hemiplegia was found with a contracted left hand containing a washcloth, but their care plan lacked interventions to address the contracture. The Nursing Home Administrator confirmed the oversight, and a Hospice RN reported cleaning green slime from the hand. Despite these issues, the care plan remained inadequate, leading to a deficiency.
A resident with significant medical conditions, including diabetes and hemiplegia, experienced a 14.71% weight loss due to the facility's failure to consistently monitor and document nutrition and hydration intake. The resident required one-on-one feeding assistance, but staff did not consistently document meal and fluid intake, and the care plan lacked an intervention for hourly water provision. The facility's limited education efforts and reliance on agency CNAs contributed to the deficiency.
A resident with Huntington's disease and moderate cognitive impairment repeatedly exited the facility unsupervised, posing significant safety risks. The facility failed to implement effective monitoring and intervention strategies, resulting in multiple incidents where the resident was found by police walking on highways and country roads. Despite the resident's refusal to wear a Wanderguard, the facility did not adequately assess or address the resident's risk for elopement.
A resident with Huntington's disease and a history of suicide attempts did not receive appropriate psychiatric follow-up or expedited guardianship at a facility. Despite repeated elopements and unsafe behavior, the facility failed to reassess the resident's needs or make necessary referrals, leading to multiple incidents where the resident was found in dangerous situations. Interviews revealed a lack of timely action and communication regarding the resident's safety and psychiatric needs.
The facility did not implement its abuse policy properly, as it failed to complete an out-of-state background check for the DON and had an incomplete BID form for a Laundry Aide. The BOM, new to the HR role, acknowledged these oversights.
A survey identified multiple infection control deficiencies in an LTC facility, including incomplete infection surveillance records, inadequate hand hygiene by a CNA during resident care, improper storage and use of medical supplies in a resident's room, and failure by an LPN to sanitize a blood pressure cuff between residents. The DON acknowledged these issues, which affected the facility's ability to prevent the transmission of infections.
A resident was observed with medications at their bedside without an accurate self-administration assessment or physician's order reflecting the allowed medications. The care plan lacked details on medication storage, and discrepancies were found between the physician's orders and the medications being self-administered. The resident, with intact cognition, was responsible for their healthcare decisions but was not correctly assessed for self-administration capabilities.
A resident with PTSD, anxiety, and depression was admitted to a facility without a proper PASRR Level II Screen due to an inaccurate Level I Screen. The oversight was confirmed by the facility's MDS coordinator and DON, who acknowledged that the resident's mental health diagnoses should have triggered a Level II Screen.
The facility failed to implement comprehensive care plans for two residents. One resident's care plan did not reflect the need for bed rails, despite the resident's request and the facility's policy requiring a person-centered approach. Another resident's care plan did not include a preference for caregivers of the same gender, despite a history of sexual assault. The Director of Nursing confirmed that these individualized interventions should have been included.
A resident with severe cognitive impairment did not receive routine nail care as required by the facility's policy. Observations revealed the resident's toenails were overgrown and causing discomfort. Staff interviews indicated inconsistencies in nail care practices, with records showing the resident's nails had not been trimmed since admission.
The facility failed to maintain accurate documentation for two residents regarding the use of assistive devices. One resident's care plan did not reflect the use of bed rails, and assessments were not documented. Another resident's cane was removed without proper documentation of the incident or discussion. These deficiencies were identified through observations and interviews, highlighting gaps in the facility's compliance with medical record-keeping standards.
The facility failed to ensure that call lights were within reach for three residents, including one with cerebral infarction and another with chronic pain syndrome. Observations revealed that call lights were either placed out of reach or obstructed, preventing residents from notifying staff for assistance.
A facility failed to administer hydrocortisone to a resident with a history of cerebral infarction and anxiety disorder due to an unaddressed allergy concern, delaying the medication despite physician orders. Additionally, a nurse improperly disposed of a half tablet of buspirone in the garbage instead of using a Drugbuster, as per facility policy, during medication administration for a resident with bipolar disorder.
The facility failed to document, investigate, or resolve grievances for two residents who reported issues with a CNA. One resident was not changed from the previous day, and another was left wet and ignored. The facility did not follow its policy for prompt grievance resolution, and the concerns were not properly documented or investigated.
Failure to Report Allegations of Abuse and Exploitation to State Agency
Penalty
Summary
The facility failed to report allegations of abuse and exploitation to the State Agency as required by its Abuse, Neglect and Exploitation policy. The policy, revised 7/1/25, required reporting all alleged violations to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes, including within 2 hours for allegations involving abuse or serious bodily injury and within 24 hours for other allegations. A cognitively intact resident, with a BIMS score of 14/15 and diagnoses including drug-induced adrenocortical insufficiency, rheumatoid arthritis, anxiety, and depression, filed a grievance on 2/6/26 stating that a CNA told the resident they could not get out of bed if they only wanted to be up in a wheelchair for an hour. The DON confirmed the resident had reported that the CNA refused to get the resident into the wheelchair during an overnight shift if the resident only wanted to be up for an hour, and that the CNA later stated they had told the resident they might not be able to return in an hour due to assisting other residents. This allegation of abuse was not reported to the State Agency. The facility also did not report an allegation of exploitation involving the same resident and the same CNA. A progress note by the social worker designee documented that the resident had spoken with attorneys and was advised to inform the facility that the resident had given the CNA a tumbler as a gift, and that the resident knew they were not supposed to give gifts to staff. The DON stated that the resident had informed her that the resident purchased a mug for the CNA, who initially refused it multiple times but eventually accepted it due to pressure from the resident. During interviews, both the NHA and DON confirmed that allegations of exploitation should be reported to the State Agency, but this allegation was not reported, resulting in a failure to follow the facility’s own reporting procedures for abuse and exploitation.
Failure to Thoroughly Investigate Allegations of Abuse and Exploitation
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and exploitation involving one cognitively intact resident, R4. R4, who had diagnoses including drug-induced adrenocortical insufficiency, rheumatoid arthritis, anxiety, and depression and a BIMS score of 14/15, filed a grievance stating that a CNA told R4 they could not get out of bed if they only wanted to be up in a wheelchair for an hour. The grievance, reviewed by the DON, was summarized as R4 requesting to get up but changing their mind due to the length of time they would need to remain in the wheelchair, and staff were noted as having been educated on residents’ rights to choose when to be out of bed. However, the facility did not interview other residents or staff to determine if similar incidents had occurred, and the CNA involved was not removed from resident care during the investigation. The NHA and DON later acknowledged that a more thorough investigation of this abuse allegation should have been completed. The facility also did not fully investigate an allegation of potential exploitation when R4 reported having purchased and given a tumbler/mug as a gift to the same CNA. R4 told the social worker designee that attorneys had advised R4 to inform the facility about the gift and acknowledged knowing residents were not supposed to give gifts to staff. The DON confirmed that R4 reported buying a mug for the CNA, that the CNA initially refused it multiple times but ultimately accepted it due to pressure from R4, and that the mug was later returned. Although the facility had documentation that staff were educated on not accepting gifts from residents, there was no evidence that other residents or staff were interviewed to determine whether other gifts had been given and accepted. The NHA and DON agreed that the allegation of exploitation was not investigated thoroughly.
Failure to Clean and Document CPAP/BiPAP/AVAP Equipment per Orders and Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure CPAP/BiPAP/AVAP equipment was cleaned according to physician orders and the facility’s CPAP/BiPAP Cleaning policy for three residents using respiratory support devices. The policy, revised 6/11/25, required daily cleaning of mask frames after use with CPAP cleaning wipes or soap and water, with proper drying and storage, in accordance with CDC guidelines and manufacturer recommendations. For one resident with paraplegia and obstructive sleep apnea, the medical record showed an AVAP order to clean the mask daily starting 12/14/23, but the December 2025 Treatment Administration Record (TAR) did not contain an order to clean the AVAP mask on 12/4/25. This resident, who was cognitively intact and responsible for their own healthcare decisions, reported that lack of AVAP mask cleaning, along with staff popping a pimple, started irritation on the face, and was diagnosed with facial cellulitis on 12/15/25. A second resident with obesity and obstructive sleep apnea had an order to clean the CPAP mask, headgear, and tubing with mild soap and warm water each morning every Friday for sleep apnea care, starting 12/14/24. This resident, also cognitively intact and responsible for their own healthcare decisions, reported the CPAP mask had been washed only once since admission. The March 2026 TAR showed CPAP cleaning entries marked with a “4” on two dates, indicating a nursing progress note should explain why the treatment was not completed, but no such progress notes were found in the medical record, as confirmed by the DON. A third resident with acute and chronic respiratory failure with hypoxia and an activated POA for healthcare had an order to clean the BiPAP mask once daily starting 2/14/26; this resident was unsure if staff cleaned the mask daily, and the March 2026 TAR lacked documentation of BiPAP cleaning on one date. An LPN stated nurses were responsible for cleaning CPAP/BiPAP/AVAP masks and documenting this in the TAR, and the DON confirmed that masks should be cleaned daily, tubing weekly, and that there were missing dates of completion for all three residents.
Failure to Administer Ordered Antibiotic and Notify Physician of Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an ordered antibiotic was not administered as prescribed. The resident, who was cognitively intact and responsible for their own healthcare decisions, had a history of left cheek cellulitis. On 12/15/25, nursing documentation described a 4–5 cm swollen, hard, red, warm, and painful area on the resident’s left upper cheek, with a small open center and increasing size and pain over at least three days. The nurse noted there were no prior requests to the physician for advisement, and the resident ultimately requested transfer to the ER that evening. The hospital diagnosed facial cellulitis and prescribed clindamycin 300 mg by mouth three times daily starting 12/16/25. Upon return to the facility, the clindamycin order was not carried out as written due to medication unavailability from the pharmacy. The Medication Administration Record showed that three doses on 12/16/25 and two doses on 12/17/25 were not administered, with the first documented dose given on the PM shift of 12/17/25. The facility did not notify the physician about the missed doses. During this period, the resident’s cellulitis became more painful, leading the resident to request hospital transfer again on 12/17/25 and then again on 12/20/25. Subsequent hospital records documented a MRSA left cheek abscess with preseptal cellulitis requiring irrigation, debridement, wound packing, IV vancomycin, and continued wound care and oral antibiotics after discharge. The DON confirmed that clindamycin was not available in contingency stock, the pharmacy did not deliver it timely, and that the resident missed a total of five doses between 12/16/25 and 12/17/25.
Excessive Lint Buildup in Laundry Dryer Traps
Penalty
Summary
The facility did not ensure the resident environment remained as free of accident hazards as possible because the dryers contained excessive lint buildup. During a tour of the laundry room with the Nursing Home Administrator, the surveyor observed Dryer A with lint covering approximately three-quarters of the bottom of the lint trap and rising to about one inch high. Dryer B also contained lint buildup, with lint approximately one-half inch high covering about half the width of the lint trap. The administrator confirmed the amount of lint observed in Dryer A and indicated it did not appear to have been cleaned daily. The surveyor reviewed the lint trap cleaning documentation posted near the dryers and found the last documented cleaning date was 4/7/25. The administrator stated laundry staff should clean lint traps once daily and later provided a separate documentation sheet that indicated the lint traps were cleaned twice daily. The administrator also stated the laundry lead kept the sheet in another location because staff moved and lost it. During the observation, maintenance staff swept out the lint traps with a broom.
CPAP Used Without Orders or Cleaning Instructions
Penalty
Summary
A resident who used a CPAP machine was admitted to the facility from a hospital, but the facility did not have a physician’s order for CPAP use at the time of admission and did not have orders to maintain or clean the equipment. The resident’s MDS showed intact cognition, and the resident’s hospital discharge summary did not include CPAP orders. The resident’s baseline care plan listed oxygen use with room air and CPAP/BIPAP, but only room air was circled, indicating the facility was not aware that CPAP was part of the resident’s plan of care at admission. The resident’s record also did not contain a diagnosis supporting CPAP use when reviewed by the surveyor. The MAR and TAR did not include orders or treatments related to the CPAP machine. During observation, the resident was seen in bed wearing a face mask attached to a CPAP machine, and the resident stated the facility provided distilled water for the reservoir but did not provide supplies to clean the mask, tubing, or machine, and staff had not cleaned the equipment either. The resident also stated the machine worked and was set at 20, which differed from the machine used at home. The facility administrator stated there should be orders in the TAR to wash and maintain the hose and mask. The DON verified that the discharge summary did not contain CPAP orders and stated the facility had been informed before admission that the resident would need a CPAP machine, so a machine was ordered in preparation for admission. The DON also stated CPAP orders were not entered even though the machine was already set up in the resident’s room, and that the facility was working on obtaining orders and a diagnosis for CPAP use along with orders to care for the equipment. Later, the resident’s record was updated with CPAP use orders, cleaning orders, and a diagnosis of obstructive sleep apnea.
Failure to Obtain and Administer Ordered Pneumococcal Vaccines
Penalty
Summary
The facility did not ensure that three sampled residents who had signed consent to receive pneumococcal vaccination actually received the vaccine. R38, R35, and R8 each had informed consent forms in their records indicating consent for available vaccinations, including pneumococcal vaccines, but their records did not show that the Prevnar 20 vaccine was administered. The facility’s immunization policy stated that residents may receive vaccinations under physician-approved standing orders or with a practitioner order, and that if vaccine availability was an issue, the facility would demonstrate that the vaccine had been ordered or that shipment confirmation had been received. R38 was admitted with diagnoses including fusion of the spine and severe protein-calorie malnutrition, and had a BIMS score of 11, indicating moderately impaired cognition; R38 was own decision maker. R38 signed consent for influenza, pneumococcal, RSV, and COVID-19 vaccines, and a physician order form indicated RSV and Prevnar 20 could be given now, with the COVID-19 booster to be given with influenza vaccine when available. R38 received RSV at the facility, but the Prevnar 20 vaccine was left blank and the record did not show that it was administered. R35 was admitted with CHF, renal insufficiency, ESRD, diabetes mellitus, and COPD, had a BIMS score of 12, and was own decision maker. R35 also signed consent for all available vaccines, and a physician order form indicated RSV and Prevnar 20 could be given now, but the record did not show that R35 received Prevnar 20 or RSV. R8 was admitted with diagnoses including paroxysmal A-fib, dementia, and cerebral infarction due to occlusion or stenosis of a small artery, and had a BIMS score of 0 with an activated POAHC. R8’s POAHC signed consent for all available vaccines, and a physician order form and physician response indicated R8 could receive RSV and a COVID-19 booster. However, the record did not show that R8 received Prevnar 20, and an order for Prevnar 20 was not obtained. During interviews, the NHA and DON stated the vaccines had not been received because the orders were not submitted correctly and there was miscommunication with the pharmacy, and the DON acknowledged that the facility had not obtained the Prevnar order for R8.
Missed COVID-19 Vaccine Order and Education for a Resident
Penalty
Summary
The facility did not ensure that one resident, R33, received education regarding the risks and benefits of the COVID-19 vaccine and did not ensure the vaccine was administered after the resident requested it. R33 was admitted with diagnoses including spondylosis without myelopathy or radiculopathy of the cervical region, mild protein-calorie malnutrition, diabetes with diabetic neuropathy, and COPD. The resident’s MDS assessment showed a BIMS score of 15 out of 15, indicating intact cognition, and R33 was the decision maker for self. The medical record contained a signed informed consent dated 2/20/25 indicating consent for available vaccines, including COVID-19. The record also included a physician order sheet dated 8/20/25 indicating R33 could receive a COVID-19 and RSV vaccine, but the medical record did not show that either vaccine was administered. Survey review found the facility did not transcribe the physician’s order for the vaccines or process it for administration. The NHA later verified that the order had been missed, confirmed the resident had signed consent on admission, and stated the facility had vaccine supplies available when R33 was admitted and consented to receive the vaccines.
Failure to Notify Physician of Resident's Worsening Skin Condition
Penalty
Summary
The facility failed to notify a physician of a change in condition for a resident, identified as R7, who was experiencing a worsening skin condition. R7, who had a history of dementia, epilepsy, schizophrenia, anxiety, and traumatic brain injury, was admitted with a moderately impaired cognitive status. The resident's skin condition, specifically redness and pain in the groin and scrotum area, was noted to have worsened over time. Despite this change, the facility did not update R7's physician about the deterioration of the skin condition, which was a requirement according to the facility's Notification of Changes policy. The issue was identified during a survey when the Nursing Home Administrator (NHA) acknowledged that the physician should have been informed of the change in R7's skin condition. Documentation showed that an antifungal powder was ordered for R7's groin area, and the care plan was updated to allow R7 to wash their own peri area. However, the lack of communication with the physician regarding the worsening condition from December to February was a deficiency in the facility's protocol for notifying changes in a resident's condition.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to ensure a grievance was documented, thoroughly investigated, and resolved for a resident, identified as R18, who was part of a sample of 19 residents. The grievance was submitted by R18's court-appointed guardian, GDN-I, who raised concerns about cleanliness, R18's roommate, and the frequency of showers. The grievance form indicated that follow-up occurred the day after the grievance was submitted, but GDN-I reported not being updated on all components of the grievance or how it was resolved. The facility's grievance policy requires that grievances be recorded, logged, and resolved with the resident or their representative being kept informed of the progress. The surveyor's review of the grievance log and interviews with GDN-I and the Nursing Home Administrator (NHA-A) revealed discrepancies in the documentation and communication of the grievance resolution. GDN-I noted that R18 had food on their clothing and surrounding areas, had not received a shower for over a week, and had an inappropriate roommate. Although some actions were taken, such as a room change and scheduling showers, GDN-I was not informed of the investigation's findings or any interventions to prevent future occurrences. NHA-A considered the initial conversation with GDN-I as follow-up but did not provide further documentation or resolution details, leading to the deficiency finding.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R1, to the State Agency as required by their policy. R1, who had a history of cerebrovascular accident, left hemiparesis, dysphagia, and diabetes, reported that a Certified Nursing Assistant (CNA-E) had grabbed and twisted R1's right wrist, causing pain. This incident was reported by R1 to an unidentified staff member and R1's Power of Attorney for Healthcare (POAHC). However, the allegation was not communicated to the State Agency or local law enforcement, as confirmed by the Nursing Home Administrator and Director of Nursing during the survey. The facility's policy mandates immediate investigation and reporting of abuse allegations to the appropriate authorities within specified time frames, particularly within two hours if the allegation involves abuse or results in serious bodily injury. Despite this, the survey revealed that the allegation, which was initially reported during the summer of 2024, was not followed up on, and the POAHC did not receive any updates regarding the investigation. Interviews with staff, including RN-G, who was informed of the incident, showed a lack of recall or action taken, contributing to the deficiency in reporting the abuse allegation as required.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident, identified as R1, who reported that a Certified Nursing Assistant (CNA-E) had grabbed and twisted their right wrist, causing pain. This incident was reported by R1 and their Power of Attorney for Healthcare (POAHC-J) to the facility staff, including a Registered Nurse (RN-G) and a Licensed Practical Nurse (LPN-H). However, the facility did not conduct a comprehensive investigation as required by their Abuse, Neglect, and Exploitation policy. The policy mandates immediate investigation upon suspicion or reports of abuse, including identifying responsible staff, interviewing all involved parties, and documenting the investigation thoroughly. Despite the report of abuse, the facility did not obtain statements from R1, CNA-E, or other potential witnesses, and there was no follow-up with POAHC-J regarding the allegation. During the survey, the Nursing Home Administrator (NHA-A) and Director of Nursing (DON-B) indicated they were unaware of the allegation. The lack of a thorough investigation and documentation of the incident represents a deficiency in the facility's handling of abuse allegations, as outlined in their policy.
Unqualified Staff Performing Personal Care Tasks
Penalty
Summary
The facility failed to ensure that showers, feeding assistance, and activities of daily living (ADLs) were performed by a qualified person for two residents. Hospitality Aide (HA)-D, who was not a Certified Nursing Assistant (CNA) and had not received the necessary training or competency assessments, assisted residents with personal care tasks such as showering, feeding, and transferring. This was outside the scope of HA-D's job responsibilities, which were limited to providing basic assistance without hands-on care. Resident 15 and Resident 19 were directly affected by this deficiency. Resident 15, who was not cognitively impaired, reported that HA-D completed personal care tasks such as showering and dressing. Similarly, Resident 19, who had a traumatic spinal cord injury with paraplegia and other medical conditions, indicated that HA-D assisted with showering, dressing, and transferring using a Hoyer lift. The Nursing Home Administrator and Director of Nursing were unaware of HA-D's involvement in feeding residents and confirmed that such tasks were beyond HA-D's scope of practice.
Inadequate Infection Control Practices for Resident with Catheter and Wounds
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper use of Enhanced Barrier Precautions (EBP) and hand hygiene practices for a resident with an indwelling catheter and wounds. On March 11, 2025, Certified Nursing Assistants (CNAs) E and F did not wear gowns while providing personal hygiene and catheter care to the resident, despite the facility's policy requiring gown use during high-contact resident care. Additionally, Registered Nurse (RN) G did not wear a gown or perform hand hygiene between glove changes during wound care for the same resident. The resident, who was not cognitively impaired, had multiple diagnoses including quadriplegia, diabetes, polyneuropathy, and a pressure ulcer, and was on EBP due to an indwelling urinary catheter, ostomy, and wounds. The surveyor observed that there were no gowns available near the resident's room, contrary to the facility's policy. Interviews with the CNAs, RN, Director of Nursing, and Nursing Home Administrator confirmed the failure to adhere to the infection control protocols, acknowledging that gowns should have been worn and hand hygiene should have been performed between glove changes.
Failure to Notify Physician and Guardian of Medication Refusals
Penalty
Summary
The facility failed to notify a physician and a corporate Guardian about a resident's repeated medication refusals, which is a violation of their Medication Administration policy. The policy requires physician notification if two consecutive doses of a vital medication are withheld or refused. The resident, who has moderately impaired cognition and a corporate Guardian for decision-making, refused multiple medications on several occasions in January and February 2025. These medications included those for heart health, hypertension, OCD, depression, personality disorder, GERD, and diabetes mellitus type 2. Despite these refusals, there was no documentation of physician or Guardian notification in the resident's medical record. Interviews conducted by the surveyor revealed that the resident's Guardian was unaware of the medication refusals and that these refusals were not discussed during a care conference. The Director of Nursing confirmed that staff should have contacted the resident's physician after three medication refusals, indicating a lapse in following the facility's policy. This oversight in communication and documentation led to the deficiency identified by the surveyors.
Deficiencies in Nutritional and Hydration Care for Two Residents
Penalty
Summary
The facility failed to provide adequate nutritional and hydration care for two residents, R3 and R1, leading to deficiencies in maintaining their health. R3, who had multiple diagnoses including dysphagia and moderate intellectual disability, was on a mechanical soft diet with ground meat. Despite a recommendation from Speech Therapy to upgrade R3's diet to cut-up meat, the diet order was not changed, and a swallow study was not completed. Additionally, R3's meal intakes were inconsistently documented, contributing to a 7.3% weight loss over three months. R3's guardian and family were not informed about the dietary restrictions, and there was a lack of communication and follow-up regarding the necessary dietary adjustments. R1, who had conditions including diabetes and hemiplegia, was at risk for dehydration and required total assistance with eating. The facility's staff did not consistently document or monitor R1's fluid intake, with 56.78% of shifts missing documentation. Although staff were observed offering fluids to R1, the lack of documentation made it unclear whether R1 was receiving adequate hydration. The Director of Nursing acknowledged the missing documentation and the expectation for CNAs to record fluid intake every shift. The facility's policies on nutritional management and hydration monitoring were not adhered to, resulting in inadequate care for R3 and R1. The failure to update R3's diet order and complete a swallow study, along with the inconsistent documentation of meal and fluid intake, highlighted significant lapses in the facility's care processes. These deficiencies were identified through observations, interviews, and record reviews conducted by the surveyor.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, R5 and R6, as observed during a survey. R5 did not receive the prescribed calcium 200 mg during the morning medication pass because the medication was unavailable in the facility. The Licensed Practical Nurse (LPN) responsible for administering the medication did not notify R5's physician about the missed dose, which was against the facility's Medication Administration Policy. R5 had multiple diagnoses, including a disorder of bone and chronic systolic heart failure, which necessitated the calcium supplement. R6, who had diagnoses including schizoaffective disorder and COPD, did not receive the correct form of Seroquel XR 50 mg as ordered. Instead, the LPN administered two 25 mg tablets of quetiapine, which was not the extended-release form required. This substitution was made from the facility's contingency stock without consulting the physician, resulting in a medication error. The Director of Nursing confirmed that the LPN administered an incorrect medication to R6, which was a deviation from the prescribed treatment plan.
Failure to Establish Resident Financial Account
Penalty
Summary
The facility failed to honor a resident's right to manage their financial affairs by not allowing a resident, who had a corporate guardian, to set up a petty cash fund or Resident Fund Management Service (RFMS) account. The resident, identified as R2, was admitted with diagnoses including dementia, schizophrenia, and anxiety, and had a severely impaired cognition score. Despite requests from R2's corporate guardian to establish a resident account, the facility required direct deposit account information, which the guardian could not provide due to organizational restrictions. As a result, the facility returned two checks sent by the guardian for R2, as the RFMS authorization agreement was not signed. Interviews with the Business Office Manager (BOM) and the Nursing Home Administrator (NHA) revealed that the facility did not have a process to manage petty cash accounts without a direct deposit setup. The BOM indicated that it was not the facility's responsibility to manage residents' finances without legal authority, and the NHA confirmed that the facility should handle funds if requested by residents. The resident expressed a desire to have access to money to make purchases like other residents but was unsure how to establish an account. The facility's inability to accommodate the resident's financial management needs led to the deficiency.
Failure to Address Resident's Hand Contracture
Penalty
Summary
The facility failed to provide appropriate care to prevent further decrease in range of motion for a resident with a contracted left hand. The resident, who had a history of diabetes mellitus, right hand amputation, and hemiplegia following a stroke, was observed with a contracted left hand containing a rolled-up washcloth. The resident's care plan did not include interventions to address the contracture, which was confirmed by the Nursing Home Administrator. The administrator acknowledged that the care plan should have included measures to prevent the worsening of the contracture and mentioned that therapy staff were in the process of finding a suitable piece of foam for the resident's hand. Additionally, a Hospice RN reported that a Hospice CNA had to clean green slime from the resident's left hand, which had a noticeable odor. The Hospice RN assessed the hand and found no redness or open wounds but placed a washcloth in the hand. The facility staff were informed of this issue during a care conference. Despite these observations and reports, the resident's care plan remained inadequate in addressing the contracture, leading to the deficiency noted by the surveyor.
Failure to Monitor and Document Nutrition and Hydration Intake
Penalty
Summary
The facility failed to consistently monitor and document the nutrition and hydration intake for a resident who required total assistance with eating due to significant medical conditions, including diabetes mellitus, amputation of the right hand, and hemiplegia following a stroke. The resident had orders for one-on-one feeding assistance and documentation of meal and fluid intake at each meal, which were not consistently followed. The resident's care plan was also not updated to include an intervention for staff to offer and provide water every hour, despite a significant weight loss of 14.71% over several months. Observations and interviews revealed that the facility's staff did not consistently document the resident's meal and fluid intake, with numerous missing entries noted in the Treatment Administration Records over three months. The facility's Nursing Home Administrator acknowledged the expectation for CNAs to document fluid intake every shift and confirmed that missing documentation implied the resident did not receive fluids. Additionally, the facility's education efforts to ensure the resident was fed and provided water were limited, with only a few CNAs receiving the training, and agency staff were not informed of the necessary interventions due to the care plan's lack of updates.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident, identified as R1, from repeatedly exiting the facility without signing out, which led to a finding of Immediate Jeopardy. R1, who had Huntington's disease, diabetes mellitus, chronic kidney disease, and depression, exhibited moderate cognitive impairment and decreased safety awareness. Despite these conditions, R1 was able to leave the facility multiple times, often found by police walking on highways and country roads, posing significant safety risks. The facility's policy on elopements and wandering residents was not effectively implemented for R1. R1's care plan included interventions such as arranging transportation for appointments and reminding R1 to sign out, but these measures were insufficient. R1's medical record indicated a low risk for elopement, and R1 was not included in the Wander Communication Binder, which was a critical oversight given R1's history of wandering and elopement. Staff interviews revealed a lack of consistent monitoring and intervention strategies for R1. The facility did not have a system to track R1's whereabouts, and staff often relied on police to return R1 to the facility. Despite R1's refusal to wear a Wanderguard, the facility did not explore alternative safety measures or adequately assess R1's risk for elopement, leading to repeated incidents of R1 leaving the facility unsupervised.
Removal Plan
- Educate residents who leave the facility independently to sign out with their location and when they will return.
- Offer R1 transportation to locations not within walking distance.
- Update the Wander Communication Binder.
- Initiate elopement drills.
- Reeducate staff on the elopement/wander policy, including care planning and identification of potential elopement risks.
Failure to Provide Medically-Related Social Services for Resident with Psychiatric Needs
Penalty
Summary
The facility failed to provide appropriate medically-related social services for a resident with a history of suicide attempts and psychiatric needs. The resident, who had Huntington's disease, diabetes mellitus, chronic kidney disease, and depression, was admitted to the facility without a follow-up on psychiatric services after being discharged from the hospital. The resident exhibited unsafe behaviors, such as leaving the facility multiple times and refusing medications, yet the facility did not expedite the guardianship process or ensure the continuation of psychiatric care. The facility's policy on elopements and wandering residents was not adequately followed. Despite the resident's repeated elopements and unsafe behavior, the facility did not reassess the resident's needs or make necessary referrals for psychiatric consultations. The resident's care plan indicated a risk for self-inflicted injury and decreased safety awareness, but the facility's response was insufficient, as evidenced by multiple incidents where the resident left the facility unsupervised and was found in potentially dangerous situations. Interviews with staff and external agencies revealed a lack of timely action and communication regarding the resident's safety and psychiatric needs. The facility did not seek guidance from Adult Protective Services on how to keep the resident safe while awaiting guardianship, nor did they contact the State Ombudsman for advice. The Social Services Designee admitted to not following up on the psychiatric concerns listed in the hospital discharge summary, contributing to the deficiency in care provided to the resident.
Incomplete Background Checks for Staff
Penalty
Summary
The facility failed to implement its abuse policy effectively, as evidenced by incomplete background checks for two employees. The Director of Nursing (DON)-B, who was hired in 2020, had a four-year Background Information Disclosure (BID) form completed in 2024, which indicated that the DON had resided outside the state in the past three years. However, the facility did not conduct the required out-of-state background check for DON-B. This oversight was identified during a review of the DON's background check information by a surveyor. Additionally, the facility did not have a fully completed BID form for Laundry Aide (LA)-C, who was hired in 2024. The surveyor found that pages 2 and 3 of LA-C's BID form were missing. The Business Office Manager (BOM)-D, who was new to the Human Resources role, acknowledged the missing documentation and the requirement for a complete BID form. BOM-D also confirmed the necessity of an out-of-state background check for employees who have lived outside the state within the past three years.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. The infection surveillance line list for staff was incomplete, lacking critical information such as the well date for HR-G and COVID-19 test results for CNA-F. The Director of Nursing, who also served as the Infection Preventionist, acknowledged these omissions and confirmed that the missing information was an oversight. Inadequate hand hygiene practices were observed during the provision of care for a resident with a urinary catheter. CNA-I failed to perform hand hygiene between glove changes while providing perineal and catheter care, despite the facility's policy requiring such practices. Additionally, CNA-I did not wear the appropriate personal protective equipment (PPE) as indicated by the Enhanced Barrier Precautions (EBP) policy, which was confirmed by both the CNA and the Director of Nursing. The survey also revealed improper storage and use of medical supplies in a resident's room, where used PPE and medical items were found. The resident confirmed that staff used personal supplies for care, contrary to facility policy. Furthermore, LPN-J did not sanitize a blood pressure cuff between uses on two residents, which was not in line with the facility's equipment protocol. The Director of Nursing verified that staff were expected to sanitize equipment between residents unless it was disposable.
Deficiency in Self-Administration of Medication Assessment
Penalty
Summary
The facility failed to ensure a proper self-administration of medication assessment for a resident, identified as R11, who was observed with medication at their bedside. The assessment and physician's order did not accurately reflect the medications R11 was allowed to self-administer. Additionally, R11's care plan did not specify how the medications were to be stored and secured in their room. R11, who had intact cognition and was responsible for their healthcare decisions, was observed to self-administer eye drops, nasal spray, and inhaled medications, but the care plan did not indicate the storage arrangements for these medications. The resident's medical record showed discrepancies between the physician's orders and the medications R11 was self-administering. The Medication Administration Record (MAR) did not include orders for nebulizer treatments, which were mentioned in the physician's order. Furthermore, the Self-Administration of Medication Evaluation indicated that R11 could not correctly administer eye drops or ointments, yet they were self-administering these medications. Interviews with the Director of Nursing confirmed that the care plan should have included storage details and that the physician's order should have been for an albuterol inhaler instead of a nebulizer treatment.
Failure to Complete Accurate PASRR Screening for Resident
Penalty
Summary
The facility failed to meet the Pre-Admission Screen and Resident Review (PASRR) requirements for a resident, identified as R7, who was admitted with diagnoses including post-traumatic stress disorder (PTSD), anxiety, and depression. Despite these diagnoses, R7's PASRR Level I Screen inaccurately indicated that the resident was not suspected of having a serious mental illness and did not have a current diagnosis of mental illness. This error led to the omission of a necessary PASRR Level II Screen, which should have been completed to evaluate the need for specialized services and appropriate nursing facility placement. The deficiency was identified during a surveyor's review of R7's medical records and interviews with facility staff. The Minimum Data Set (MDS) assessment for R7 showed moderate cognitive impairment, and previous medical records indicated a history of mental health issues, including suicidal ideation. The facility's MDS coordinator and Director of Nursing acknowledged the oversight, confirming that the PASRR Level I Screen should have reflected R7's mental health diagnoses, necessitating a Level II Screen. This oversight highlights a failure in the facility's adherence to PASRR guidelines, impacting the resident's care assessment process.
Deficiencies in Resident-Centered Care Plans
Penalty
Summary
The facility failed to ensure comprehensive resident-centered care plans were implemented for two residents, R7 and R15. For R7, the care plan did not indicate the need for a bed rail, despite the resident expressing a need for bilateral bed rails to assist with positioning and mobility. The facility's policy on bed rails requires a person-centered approach, but R7's care plan lacked a physician's order for bed rail use. Interviews with staff revealed confusion about R7's need for bed rails, with conflicting statements about whether R7 wanted or needed them. The Director of Nursing confirmed that an assessment should have been completed to determine the necessity of bed rails for R7. For R15, the care plan failed to address the resident's request for no caregivers of the opposite gender, despite R15's history of sexual assault. R15 expressed discomfort with a specific CNA, but the care plan did not reflect this preference. The Director of Nursing acknowledged that the individualized intervention should have been included in R15's care plan, especially given the resident's traumatic history. The oversight in both cases highlights a lack of adherence to the facility's policies and procedures for developing and implementing comprehensive care plans.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as R21, who required assistance with activities of daily living. R21 had severe cognitive impairment and was dependent on staff for all care. Despite the facility's policy that routine nail care, including trimming and filing, should be provided regularly, R21's toenails were observed to be thick, discolored, overgrown, and curling, with a substance underneath. This condition was noted during observations on two separate occasions, and R21 reported experiencing pain in the big toe. Interviews with facility staff revealed inconsistencies in the provision of nail care. A Certified Nursing Assistant (CNA) stated that nail care was part of daily grooming, while the Assistant Director of Nursing (ADON) indicated that nail care was scheduled weekly on shower days. However, records showed that R21's toenails had not been trimmed since admission. The Director of Nursing (DON) confirmed the need for trimming and acknowledged that nail care should coincide with weekly showers, highlighting a lapse in adherence to the facility's nail care policy.
Deficiencies in Documentation for Assistive Devices
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records of two residents, R7 and R10. For R7, the deficiency involved the use of bed rails. R7, who has Parkinson's disease and moderate cognitive impairment, was observed with a bed rail on the left side of the bed, despite the care plan not indicating the need for bed rails. The care plan history showed that bed rails were previously used but discontinued. The Registered Nurse (RN) stated that R7 was not reapproved for bed rail use and admitted that the assessment regarding the need for bed rails was not documented in R7's medical record. The Director of Rehab confirmed that therapy notes did not specifically address bed rail use, and the Director of Nursing acknowledged that an assessment should have been documented. For R10, the deficiency involved the removal of a cane without proper documentation. R10, who has intact cognition and a history of cerebral infarction, reported that a cane belonging to R10's grandfather was taken away by staff. The Director of Nursing stated that the cane was removed because R10 had swung it at staff, and it was kept in the office until deemed safe for R10 to use. However, this discussion and the removal of the cane were not documented in R10's medical record. A progress note indicated that R10 had previously threatened staff with the cane, but there was no documentation of the specific incident leading to the cane's removal. The lack of documentation for both residents highlights a failure in maintaining accurate medical records and ensuring that assessments and decisions regarding assistive devices are properly recorded. This deficiency was identified through observations, interviews, and record reviews conducted by the surveyor, revealing gaps in the facility's compliance with professional standards for medical record-keeping.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating their needs and preferences. Resident 1, who had cerebral infarction with left-sided paralysis and a below-elbow amputation of the right arm, was observed without a call light within reach. Despite having a soft-touch call light near the left elbow, Resident 1 was unable to use it due to the paralysis and was dependent on staff for all activities of daily living. The care plan did not specify the type or placement of the call light needed to accommodate Resident 1's physical limitations. Similarly, Resident 7, with diagnoses including congestive heart failure and diabetes mellitus, was found unable to reach the call light, which was placed on the bed while the resident was seated in a chair several feet away. Resident 8, who had chronic pain syndrome and anxiety disorder, also could not reach the call light due to its placement on the bed with a bedside table obstructing access. These observations indicate a failure to reasonably accommodate the residents' needs for assistance, as the call lights were not accessible, preventing them from notifying staff when help was needed.
Medication Administration and Handling Deficiencies
Penalty
Summary
The facility failed to ensure the accurate administration of medication for one resident and did not provide safe handling of drugs for another. One resident, who had a history of cerebral infarction, left-sided paralysis, and anxiety disorder, did not receive multiple doses of hydrocortisone as ordered by their physician. Despite a hospital discharge summary indicating the need for hydrocortisone, the facility delayed administering the medication due to an unaddressed allergy concern. The Director of Nursing acknowledged that the endocrinology orders should have been processed earlier and that there was a lack of timely transcription and clarification of physician orders. Another resident, diagnosed with bipolar disorder and an unspecified mental disorder, was observed during medication administration where a registered nurse improperly disposed of a half tablet of buspirone in the garbage. The nurse had to cut a 10 mg tablet in half to achieve the prescribed 15 mg dose, but discarded the unused half inappropriately. The nurse also failed to use a half pill that was taped in a medication card slot because they could not verify its identity. This improper disposal was contrary to the facility's policy, which requires unused medications to be disposed of in a Drugbuster or similar system.
Failure to Document and Investigate Grievances
Penalty
Summary
The facility failed to thoroughly document, investigate, or resolve grievances for two residents. One resident reported that a Certified Nursing Assistant (CNA) did not change their clothing from the previous day, and another resident reported being left wet and ignored by the same CNA. Despite these grievances, the facility did not document or investigate these concerns adequately. The facility's grievance file did not contain records of these grievances, and there was no indication that the issues were resolved. The facility's policy requires prompt efforts to resolve grievances, including documentation and investigation, which were not followed in these cases. The medical records of the two residents involved indicated that one had severely impaired cognition and an activated Power of Attorney, while the other had moderate cognitive impairment and a Guardian for decision-making. Interviews with the residents and staff revealed that the concerns were known but not properly documented or investigated. The Director of Nursing and Nursing Home Administrator acknowledged the lack of documentation and investigation, and it was noted that the CNA involved had received education on proper techniques but was still on their last chance due to ongoing issues.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 48 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.
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 Oconto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rennes Health And Rehab Center-west | 13.4 mi | ★★★★★ | 3 | 0 |
| Meadowbrook At Oconto Falls | 13.8 mi | ★★★★★ | 1 | 0 |
| Rennes Health And Rehab Center-east | 14.1 mi | ★★★★★ | 3 | 0 |
| Luther Home | 18.2 mi | ★★★★★ | 16 | 0 |
| Menominee Health Services | 20.7 mi | ★★★★★ | 3 | 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.