Above 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 The Pines Post Acute And Memory Care during CMS and state inspections, most recent first.
A medication cart was found unlocked and unattended for 10 minutes during medication administration, contrary to facility policy requiring carts to be locked or attended by authorized staff. An RN acknowledged leaving the cart unsecured, and the DON confirmed that carts should always be locked when unattended.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, or serve food according to professional standards, as observed by surveyors.
A resident with left-sided paralysis and intact cognition did not have consistent access to a call light within reach and was not provided with hearing aids as indicated in their MDS assessment. The care plan addressed fall risk and call light use but failed to include interventions for hearing needs. Staff and the DON confirmed these deficiencies, and the facility lacked a specific call light policy.
Two residents with severely impaired cognition and healthcare Guardians were transferred or discharged without receiving required written transfer or bed hold notices, and the Ombudsman was not notified as mandated by facility policy. Staff confirmed that these notifications were missed for both hospital transfers and discharges.
A resident with dementia, diabetes, and unsteadiness experienced a fall with injury while attempting to ambulate independently. After therapy staff recommended one-person assistance with a gait belt for all transfers and ambulation, the care plan was not updated, and nursing staff continued to believe the resident was independent. This lack of care plan revision and communication led to a deficiency in accident hazard prevention and supervision.
A resident did not receive enough food and fluids to maintain their health, as observed and documented by surveyors.
Staff did not consistently follow care plans for two high-risk residents, failing to ensure bed and chair alarms were in place and not adhering to specific safety instructions such as keeping a recliner footrest down. These lapses led to multiple falls, including one resulting in a hip fracture and another causing a reopened head wound, despite facility policy requiring regular checks of fall prevention interventions.
The facility did not ensure that a contracted CNA's background check documentation was available and complete, as required by state regulations. The CNA's agency withheld background check documents from the facility, citing privacy concerns, and did not follow state requirements for reviewing certain convictions. The necessary documents were only provided to the surveyor upon direct request, indicating a breakdown in the facility's process for screening agency staff.
A resident with severe cognitive impairment and a history of tearing incontinence briefs was physically restrained by a CNA, who tied the resident's nightgown sleeves with the resident's arms inside and tucked a blanket under the mattress, restricting movement and access to the call light. The restraint was discovered by an LPN during a routine check, and staff interviews confirmed the CNA's actions were not in accordance with facility policy.
The facility did not ensure a required four-year background check was completed for an agency CNA, as the only available documentation was last reviewed in 2019, despite the CNA having worked in the facility within the past three months. This was not in accordance with the facility's policy for background check frequency.
The facility failed to maintain proper temperature for a medication refrigerator and did not ensure medications for 11 residents were labeled and dated appropriately. Observations revealed temperatures above the acceptable range and multiple instances of improperly labeled or expired medications.
The facility failed to ensure safe food handling practices, as evidenced by incorrect food cooling procedures documented on six occasions. The Dietary Manager and Nursing Home Administrator confirmed that the facility follows the Wisconsin Food Code, but the cooling logs showed multiple instances where the guidelines were not followed, and corrective actions were not taken.
A resident with a history of sepsis due to a UTI did not receive proper catheter care, as a CNA cleaned the catheter tubing incorrectly, increasing the risk of infection. The DON confirmed the correct procedure was not followed.
The facility failed to provide accurate pharmaceutical services for two residents. An LPN did not follow proper procedures for administering inhalers and crushed an enteric-coated tablet, which should not be crushed. Additionally, a resident was given an unprescribed supplement.
A facility failed to maintain proper infection control during wound care for a resident on Enhanced Barrier Precautions. An LPN did not wear the required gown and did not perform appropriate hand hygiene, instead using two sets of gloves to avoid handwashing. The resident had multiple diagnoses requiring careful wound care, but the LPN's actions did not comply with the facility's infection control policy.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on the Memory Lane unit was observed by a surveyor to be unlocked and unattended for 10 minutes during medication administration. The facility's policy requires that medication carts be locked or attended by authorized personnel at all times. During the observation, a registered nurse (RN) returned to the cart and confirmed that it had been left unlocked and unattended, stating that it was an accident and not their usual practice. The Director of Nursing also confirmed that medication carts should be locked when unattended. This incident had the potential to affect more than 4 of the 44 residents in the facility.
Failure to Follow Professional Standards in Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified through surveyor observation and review of facility practices related to food procurement and handling. No additional details regarding specific residents, staff, or incidents were provided in the report.
Failure to Ensure Call Light Accessibility and Hearing Aid Provision
Penalty
Summary
A resident with a history of hemiplegia and hemiparesis following a stroke, as well as other medical conditions such as anxiety, chronic pain, asthma, and neuromuscular bladder dysfunction, was found to have deficiencies in care related to the accommodation of their needs and preferences. The resident's care plan identified a risk for falls due to left-sided weakness and included interventions to ensure the call light was within reach. However, on multiple occasions, the call light was observed to be placed on the resident's left side, which was affected by paralysis, making it inaccessible. The resident reported that staff sometimes intentionally placed the call light out of reach, requiring the use of a reacher to access needed items. Staff confirmed the call light was not within reach and only corrected its placement after being notified by the surveyor. Additionally, the resident's Minimum Data Set (MDS) assessment indicated the use of hearing aids, but the care plan did not address hearing or hearing aids. The resident was observed without hearing aids and stated that staff did not assist with putting them in, requiring the resident to request this assistance. The Director of Nursing confirmed the absence of a care plan for hearing aids and acknowledged that the call light should have been within reach due to the resident's limited mobility. The facility did not have a specific call light policy, relying instead on the standard of care.
Failure to Provide Required Transfer, Bed Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide required written transfer and/or bed hold notices, as well as Ombudsman notifications, for two residents who were transferred to the hospital or discharged. One resident, who had severely impaired cognition and a healthcare Guardian, was transferred to the hospital on three separate occasions for medical issues including a brain bleed, complicated UTI, and pneumonia. On each occasion, neither the resident nor the Guardian received a written transfer or bed hold notice, and there was no documentation that the Ombudsman was notified of the transfers or the final discharge. Staff interviews confirmed that these notifications were not completed as required by facility policy. Another resident, also with severely impaired cognition and a healthcare Guardian, was discharged to an assisted living facility without documentation that the Ombudsman was notified of the discharge. Staff interviews further verified that Ombudsman notifications for transfers and discharges were missed during the relevant period. The facility's policy requires written notification to residents or their representatives regarding bed hold rights and transfer/discharge, as well as notification to the Ombudsman, but these steps were not followed for the residents in question.
Failure to Update Care Plan After Resident Fall and Therapy Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was as free from accident hazards as possible and did not provide adequate supervision to prevent accidents for a resident with multiple risk factors. The resident, who had diagnoses including dementia, diabetes mellitus type 2, unsteadiness on feet, long-term use of anticoagulants, and general weakness, experienced a fall with injury. The resident had severely impaired cognition and an activated Power of Attorney for Healthcare. On the day of the fall, the resident attempted to ambulate independently to the restroom, using a walker and wearing gripper socks, but fell and sustained a head injury. Staff responded after hearing the resident call for help and observed the walker on the resident's chest. Following the fall, the facility referred the resident for physical and occupational therapy, and therapy staff determined that the resident required assistance of one staff member with a gait belt for all transfers and ambulation. However, the resident's care plan was not updated to reflect these new recommendations, and nursing and CNA staff continued to believe the resident was independent with transfers and ambulation unless assistance was requested. Communication of the therapy recommendations occurred during a morning meeting, but the care plan was not revised, and staff relied on outdated information. This failure to update the care plan and ensure all staff were aware of the resident's current needs contributed to the deficiency.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The report specifically notes the lack of provision of adequate food and fluids necessary for the resident's health maintenance.
Failure to Implement Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
Staff failed to implement and maintain required fall prevention interventions for two residents identified as being at high risk for falls. One resident with Parkinson's disease and moderate cognitive impairment had a care plan specifying the use of bed and chair alarms to alert staff of self-ambulation and a restriction against raising the footrest of the recliner. Despite these interventions, the resident was found on the floor with a reopened suture above the right eye after staff did not activate the bed alarm when assisting the resident to bed. Additionally, staff were observed raising the recliner footrest, contrary to the care plan instructions, and some staff were unaware of the need for a bed alarm. Another resident with dementia, multiple sclerosis, and a history of falls had a care plan requiring bed and chair alarms and two-person pivot transfers with a gait belt and walker. The resident experienced multiple falls when staff failed to ensure the presence of required alarms. On one occasion, the resident fell and sustained a hip fracture after the chair alarm was not in place, and the sensor pad was found on the floor. Staff interviews revealed a lack of awareness regarding the need for chair alarms, and the resident was last seen in a wheelchair before self-transferring and falling. The facility's own Falls Program policy required staff to check for correct application of care-planned interventions at the beginning of every shift, including alarms and other safety devices. Despite this policy, staff did not consistently follow care plan interventions for fall prevention, resulting in multiple falls and injuries for both residents.
Failure to Ensure Proper Background Checks for Agency CNA
Penalty
Summary
The facility failed to implement and enforce written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation of resident property, as evidenced by incomplete caregiver background checks for one of eight staff reviewed. Specifically, a contracted CNA's background check documentation was not available in the facility's records, and the facility was unable to provide the required Wisconsin DOJ criminal background check letter or IBIS letter for this staff member. The Human Resource Manager indicated that the staffing agency no longer provided these documents to the facility due to privacy concerns and a previous data breach. Further investigation revealed that the agency employing the CNA did not follow the Wisconsin Caregiver Program requirements regarding offenses affecting caregiver eligibility, particularly for convictions of disorderly conduct. The agency manager was unaware of the specific state requirements and relied on the agency's own hiring standards, which did not include a detailed review of certain convictions. The necessary background check documents were only provided to the surveyor after direct request, highlighting a lapse in the facility's process for ensuring all staff, including agency staff, are properly screened according to state regulations.
Resident Physically Restrained by CNA Using Nightgown and Blanket
Penalty
Summary
A resident with Alzheimer's disease, hemiplegia, hemiparesis, major depressive disorder, and aphasia, who required total assistance for lower torso care and had a history of tearing apart incontinence briefs, was physically restrained by a Certified Nursing Assistant (CNA) during a PM shift. The CNA tied the sleeves of the resident's nightgown closed with the resident's arms inside and tucked a blanket across the resident's lap and under both sides of the mattress. This action was taken after the resident repeatedly attempted to remove their brief. As a result, the resident was unable to access their hands, move freely in bed, or reach the call light. The restraint was discovered by a Licensed Practical Nurse (LPN) during a routine check on the next shift, approximately two and a half hours later. The LPN found the resident with their arms inside the nightgown and a blanket tucked under the mattress, immediately untied the sleeves, and provided care. The resident was assessed for physical and psychological harm, with no new injuries noted, although bruising was observed on the tops of the resident's hands, which was determined not to be new. The resident, when interviewed, was only able to provide limited responses but indicated feeling fine and not having been hurt. Staff interviews and record reviews confirmed that the CNA had restrained the resident to prevent them from tearing at their brief and throwing items. The facility's policy prohibits the use of physical restraints for discipline or convenience and defines a physical restraint as any method that restricts freedom of movement or normal access to one's body. The CNA acknowledged in a statement that tying the sleeves was a poor decision, and the facility determined that the resident had been restrained during the last rounds of the PM shift.
Removal Plan
- Initiated physical and psychosocial monitoring for R1.
- Completed skin assessment for other cognitively impaired residents.
- Notified CNA-C's staffing agency and did not allow CNA-C to return to the facility.
- Educated facility and agency staff on the facility's abuse and restraint policies.
Failure to Complete Timely Background Check for Agency CNA
Penalty
Summary
The facility failed to implement its own policies and procedures regarding the prevention of abuse, neglect, and theft by not ensuring a timely and thorough background check for one Certified Nursing Assistant (CNA-H) out of eight sampled staff. According to the facility's Pre-Employment Investigations policy, background checks, including a Background Information Disclosure (BID) form, Department of Justice (DOJ) report, and Integrated Background Information System (IBIS) letter, are required every four years for all staff, including agency staff. Surveyor review revealed that CNA-H, an agency CNA who began working at the facility on 7/1/23, only had background check documentation dated 8/14/19, which was last completed and reviewed by the agency. The Nursing Home Administrator confirmed that CNA-H had worked in the facility within the last three months and that no updated background check had been obtained since 2019, despite the facility's policy requiring such checks every four years.
Improper Medication Storage and Labeling
Penalty
Summary
The facility did not ensure that one of the two refrigerators in the medication storage room, which contained vaccines and insulin, maintained a temperature between 36 and 46 degrees Fahrenheit. Observations revealed that the refrigerator's temperature was consistently above the acceptable range, with readings of 52 and 54 degrees. The temperature logs indicated multiple instances where the temperature exceeded 46 degrees, and the logs were not filled out twice daily as required. The Director of Nursing (DON) was unaware of the correct temperature range and the frequency of temperature checks, which contributed to the deficiency in maintaining proper storage conditions for temperature-sensitive medications. Additionally, the facility failed to ensure that medications for 11 residents were labeled and dated appropriately. Observations of three medication carts revealed multiple instances of improperly labeled or expired medications, including insulin pens, inhalers, and eye drops. The Medication Tech confirmed the improper labeling and expiration of these medications. The DON and Pharmacist also confirmed that the medications should have contained open/expiration dates and resident names and should have been disposed of when beyond the open date timeframe guidelines.
Improper Food Cooling Practices
Penalty
Summary
The facility did not ensure safe food handling practices were implemented, as evidenced by incorrect food cooling procedures documented on six occasions from December 2023 to April 2024. During an initial tour of the kitchen, the Dietary Manager (DM) indicated that the facility follows the Wisconsin Food Code, which requires cooked time/temperature control for safety food to be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours, and then to 41 degrees Fahrenheit or less within a total of 6 hours. However, the facility's food cooling logs showed multiple instances where these guidelines were not followed, and corrective actions were not taken as required. For example, on 12/24/23, a roast was recorded with a start temperature of 191 degrees Fahrenheit, but the 2-hour cooling temperature was incorrectly logged as 201 degrees Fahrenheit, and no corrective action was noted. Similar issues were found with entries for meat sauce, lasagna, chicken noodle, and other foods, where the cooling temperatures did not meet the required standards, and corrective actions were either not documented or not taken. On 5/14/24, the Surveyor interviewed the Dietary Manager, who confirmed that cooked food should be cooled to 70 degrees Fahrenheit within 2 hours and to 41 degrees Fahrenheit within a total of 6 hours. The Surveyor reviewed the cooling log entries with the Dietary Manager, who acknowledged that kitchen staff should be re-educated on the food cooling process. The Nursing Home Administrator also confirmed that the facility uses the [NAME] Cooling Food document as their policy/procedure for cooling food and follows the Wisconsin Food Code. The review of the food cooling entries with the Nursing Home Administrator indicated that education was initiated for kitchen staff on proper cooling methods, but the deficiencies in the cooling process were evident in the logs reviewed.
Improper Catheter Care Leading to Increased Risk of UTI
Penalty
Summary
The facility did not ensure that a resident received appropriate catheter care to prevent urinary tract infections (UTIs). The resident had a history of sepsis due to a UTI and was recently prescribed an antibiotic for this condition. During an observation, a Certified Nursing Assistant (CNA) was seen cleaning the length of the Foley catheter tubing incorrectly, starting from the drainage bag and moving toward the resident, which is contrary to the facility's policy that mandates cleaning from the resident toward the drainage bag to prevent infection. The CNA admitted to not knowing the proper procedure for catheter care. The Director of Nursing (DON) confirmed that the correct procedure is to clean the catheter from the resident toward the drainage bag. The resident involved had moderately impaired cognition and an activated healthcare decision maker. The deficiency was identified during a review of the resident's medical record and an observation of the CNA's catheter care technique.
Pharmaceutical Services Deficiency
Penalty
Summary
The facility did not provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for two residents. An LPN administered an Advair Diskus inhaler to a resident with severe cognitive impairment without offering water for rinsing and spitting as required. Additionally, the LPN crushed an enteric-coated ferrous sulfate tablet, which should not be crushed, per the medication's guidelines. The resident's medical record confirmed the necessity of these actions, and the LPN acknowledged the error during an interview. Another resident with severe cognitive impairment was administered a Breo Ellipta inhaler without being offered water to rinse and spit as required. Furthermore, the LPN provided this resident with 120 cc of Med Pass 2.0, a supplement not ordered for the resident. The resident's medical record indicated a different supplement was to be provided, and the DON confirmed that Med Pass 2.0 was not the correct supplement. These actions were observed and verified through staff interviews and record reviews.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection during the provision of wound care for a resident on Enhanced Barrier Precautions (EBP). During an observation, an LPN did not don the appropriate personal protective equipment (PPE) and did not perform appropriate hand hygiene while providing wound care to the resident. The LPN only wore two sets of gloves and did not use a gown, which is required for high-contact resident care activities under EBP guidelines. The resident had multiple diagnoses, including a methicillin-susceptible Staphylococcus aureus (MSSA) infection, a non-pressure chronic ulcer of the left calf, and local infection of the skin and subcutaneous tissue. The resident's medical record indicated the need for wound care to bilateral lower extremities, which included cleansing with mild soap and water, applying ammonium lactate to dry areas, and using ABD pads and Kerlix for weeping areas. Despite these requirements, the LPN failed to follow proper infection control procedures during the wound care process. The LPN admitted to not wearing a gown and confirmed the practice of wearing two sets of gloves to avoid performing hand hygiene between steps of the wound care process. Additionally, the LPN did not perform hand hygiene after leaving the resident's room to get more supplies and before resuming wound care. The Director of Nursing confirmed that the LPN's actions were not in accordance with the facility's infection control policy and procedure, and the LPN was subsequently educated on the correct practices.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 42 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 Clintonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greentree Health And Rehabilitation Center | 4.7 mi | ★★★★★ | 2 | 0 |
| Shawano Health Services | 7.1 mi | ★★★★★ | 14 | 0 |
| Evergreen Health Services | 7.4 mi | ★★★★★ | 4 | 1 |
| Birch Hill Health Services | 7.7 mi | ★★★★★ | 11 | 0 |
| Manawa Com Nur Ctr | 18.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.