Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Wi Veterans Home Moses Hall during CMS and state inspections, most recent first.
A resident with anoxic brain damage, dysphagia, dementia, and impulsive eating behaviors was on a regular texture diet with thickened liquids, with the POA accepting risks for quality-of-life food choices. While being assisted with a meal that included a peanut butter sandwich, the resident grabbed half the sandwich, placed it in the mouth, and began choking when the CNA briefly stepped away to get a towel. On return, the CNA noted breathing difficulty, activated emergency systems, and nurses responded and performed the Heimlich maneuver. The resident became unresponsive, was moved to the floor, and staff continued the Heimlich until the resident became pulseless and apneic. Staff did not call 911 or initiate CPR, citing the resident’s DNR status, even though facility policy required calling 911 for complete choking while the person was still breathing; the medical examiner later confirmed death due to choking.
Two residents with dysphagia and cognitive/vision impairments were not provided their prescribed adaptive drinking and dining equipment during meals, contrary to facility policy and care plans. One resident with MS, early-onset Alzheimer’s disease, and moderate cognitive impairment was served hot, thickened coffee in an uncovered cup and, while attempting to pour it into a personal thermal mug without supervision, spilled it into the lap, causing bilateral thigh burns with blistering. Another legally blind resident with vascular dementia and dysphagia was served lunch with an open coffee cup and a blue plate instead of the ordered lidded cup and white divided plate, and was observed searching for utensils until staff intervened. Staff interviews showed reliance on care plans/Kardex at the nurses’ station to identify adaptive equipment, incomplete dysphagia cards, and delayed delivery of the adaptive equipment bin, while a coffee sample from the same cart was measured at a temperature capable of causing severe burns within seconds.
A resident with dementia, hallucinations, mood disturbance, and moderately impaired cognition made two separate allegations of physical abuse by staff. The facility’s abuse policy required a thorough investigation, including identifying possible witnesses and having RNs follow up with all staff on duty during the time of the alleged incidents and the two prior shifts. However, for each allegation, only one or two staff members were interviewed, despite other staff being on the unit or assigned to the resident. Leadership (DON, ADON, NHA) acknowledged that additional staff who were working at the time should have been interviewed but were not, resulting in incomplete investigations of the abuse allegations.
Two residents experienced significant medication errors when duplicate medication orders were not properly discontinued, resulting in one resident receiving double doses of baclofen and requiring hospitalization, and another receiving double doses of long-acting insulin, leading to episodes of hypoglycemia. Facility staff did not follow established procedures for order transcription, review, or error investigation, contributing to these incidents.
Surveyors found that food items for resident consumption were not properly labeled or were past discard dates, and kitchen equipment was not maintained in a clean or covered condition. The Dietary Manager confirmed these lapses, which did not meet professional standards for food storage, preparation, and equipment sanitation.
A resident reported $150 missing from their room, but the facility failed to thoroughly investigate the allegation. The resident, who was not cognitively impaired, had withdrawn the money for a shopping trip and refused secure storage. The investigation did not include interviews with all staff who had access to the resident's room, contrary to facility policy.
A resident with Alzheimer's dementia and a history of falls did not have a call light within reach while seated in a recliner. The call light was observed wrapped around a trapezius bar above the bed, making it inaccessible. An LPN and the DON confirmed the call light was not within reach, which was not in accordance with facility policy.
A resident with a suprapubic urinary catheter did not receive documented routine site care to prevent UTIs. Staff and the DON were unable to provide evidence or a clear policy for suprapubic catheter care, and the resident's medical record lacked documentation of such care, despite the resident's history of frequent UTIs.
A resident with multiple chronic conditions was found receiving oxygen therapy without a current physician order or care plan, and the oxygen equipment in use was not properly labeled or maintained according to facility policy. Staff confirmed the absence of required documentation and oversight for the resident's oxygen therapy.
Two residents on enhanced barrier precautions due to indwelling medical devices did not receive proper infection control measures when an LPN failed to wear a gown during high-contact care activities, such as catheter care and G-tube medication administration, despite facility policy requiring gown use for these procedures.
Failure to Follow Choking Policy and Call 911 During Complete Airway Obstruction
Penalty
Summary
The deficiency involves the facility’s failure to follow its choking incident policy for a member who experienced a complete choking episode while still breathing. The member had multiple diagnoses including anoxic brain damage, dysphagia, dementia with mood disturbance and anxiety, impulse disorder, unspecified psychosis, personality change due to a known physiological condition, and aphasia. The member’s MDS showed intact cognition, and the member had an activated POA for healthcare who was actively involved in care. The member’s diet order included a general diet with regular texture and honey-thick liquids, and the care plan documented dysphagia therapy, the need for assistance with eating meals, and that the POA accepted the risks of the member consuming items outside the ordered diet for pleasure and quality of life. On the day of the incident, a CNA was assisting the member with supper in the dining room. The meal included beverages, diced pears, and a peanut butter sandwich cut in half. The member refused a drink, grabbed half of the sandwich, and shoved it into the mouth, then requested a towel for the lap. The CNA stepped away a short distance to retrieve a towel from a nearby linen cart. When the CNA returned, the member was noted to be having trouble breathing, and the CNA activated the emergency systems and requested another CNA to get the nurse. The member’s history included impulsive behavior, lack of judgment, disorganized eating and swallowing, and a tendency to become agitated if food was modified or sandwiches were cut into smaller pieces, and the speech pathologist confirmed the member required one staff for supervision during meals and that the care plan did not include an intervention to keep meal trays out of the member’s reach. In response to the choking episode, the RN supervisor and an RN arrived and initiated the Heimlich maneuver. The member became unresponsive but still had a pulse, and staff moved the member from the wheelchair to the floor and continued the Heimlich maneuver until the member became pulseless and non-breathing. Staff did not call 911 or initiate CPR because the member’s code status was DNR, despite the facility’s choking incident policy directing staff to call 911 when a person shows signs of complete choking and is still breathing. The medical examiner later confirmed the cause of death as choking, and the nursing home administrator verified that staff did not follow the facility’s choking policy and procedure and did not call 911 when the member showed signs of complete choking.
Failure to Provide Prescribed Adaptive Drinking Equipment Resulting in Coffee Burns
Penalty
Summary
The deficiency involves the facility’s failure to ensure adaptive eating and drinking equipment was used during meals to prevent burns for two members, M2 and M6, as required by facility policy and their care plans. The facility’s Adaptive Equipment policy and Member Meals and Snacks policy required that adaptive equipment be available and provided at needed meal times, based on care plans. M2’s care plan included an intervention for an insulated coffee mug with lid, and M2 had orders for a general ground diet with nectar thick liquids. Despite this, on the evening of 3/1/26, M2 was served supper with hot, thickened coffee in an uncovered cup placed within reach. The CNA who delivered the tray removed the lid from the coffee cup to allow it to cool and then left to retrieve M2’s adaptive equipment, leaving M2 alone with the uncovered hot coffee. While the CNA was away, M2, who had multiple diagnoses including MS, generalized muscle weakness, early onset Alzheimer’s disease, dysphagia (oropharyngeal phase), and moderate cognitive impairment (BIMS score 9/15), attempted to pour the hot, thickened coffee from the uncovered cup into a personal thermal mug. M2 missed the mug, and the coffee spilled into M2’s lap, resulting in burns to both thighs. Initial assessment noted a reddened area on the right upper thigh, and a wound assessment the following day documented an intact blister on the left thigh and a partially intact blister with granulation tissue and scant exudate on the right thigh. The incident was documented in a facility-reported incident, and the burns were directly linked to the spill of hot coffee that had been provided without the prescribed adaptive covered mug. For M6, the facility also failed to provide prescribed adaptive equipment during a meal. M6 had diagnoses including GERD, legal blindness, vascular dementia, dysphagia oral phase, and esophageal obstruction, with moderate cognitive impairment (BIMS 12/15). M6’s care plan specified adaptive equipment including a coffee cup with lid and a white deep dish divided plate. During a lunch observation, M6 was served a meal with an open cup of coffee and a blue plate instead of the ordered white divided plate. M6, who is legally blind, was observed feeling around for silverware until staff assisted by explaining the food and helping locate utensils. Staff interviews revealed that adaptive equipment information was only available in the care plan/Kardex at the nurses’ station, that M6’s adaptive equipment bin arrived late after M6 had already been served, and that M6’s dysphagia card did not list needed adaptive equipment. A coffee sample from the same cart used for M6’s meal measured 146.6°F, and surveyors noted that third-degree burns can occur at similar temperatures within seconds.
Failure to Thoroughly Investigate Resident Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate two separate allegations of staff physical abuse made by one member, M3, in accordance with its own Prohibition and Prevention of Member Abuse, Neglect, and Exploitation policy. The policy, revised July 2024, requires the Nursing Supervisor or Administrator to immediately initiate reporting and conduct a thorough investigation, including obtaining a list of possible witnesses, placing staff statement forms on the 24‑hour board, and ensuring RNs follow up with all staff who were on duty and may have provided care during the time of the alleged incident and the two previous shifts. M3, who had dementia with Lewy body disorder, dementia with moderate agitation, visual hallucinations, mood disturbance, a BIMS score of 9/15 indicating moderately impaired cognition, and an activated POAHC, made abuse allegations on 12/15/25 and 1/3/26. Surveyor review of the investigations and staff schedules for the 12/14/25 night shift and 1/3/26 showed that staff who were working at the time of the allegations were not interviewed. For the 12/15/25 incident, only RN‑G and CNA‑F were interviewed, despite other staff being assigned to the unit; the ADON stated that other staff were assisting on another unit when the incident occurred but acknowledged they should have been interviewed. For the 1/3/26 incident, the investigation file contained only an email statement from RN‑H, with no other staff statements, and both the NHA and DON confirmed that other staff working at the time should have been interviewed but were not. These omissions demonstrate that the facility did not complete the required comprehensive staff interviews for either abuse allegation.
Significant Medication Errors Due to Order Transcription and Administration Failures
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication order transcription and administration processes. One resident with Parkinson's disease and chronic kidney disease received five extra doses of baclofen over two days as a result of a duplicate order not being discontinued when a new order was entered. The resident exhibited symptoms of overdose, including extreme drowsiness, leg tremors, confusion, and was ultimately transported to the hospital for evaluation and treatment. The duplicate orders were present in the medication administration record, and the error was not identified until after multiple double doses had been administered. Another resident with type 2 diabetes mellitus was affected by a medication error involving long-acting insulin. The resident was supposed to transition from one insulin product to another when the initial supply was exhausted, but both insulin orders remained active in the system. As a result, the resident received double doses of long-acting insulin on two occasions, which led to episodes of asymptomatic hypoglycemia detected by a continuous glucose monitoring device. The error was not identified or investigated by facility staff at the time. In both cases, the facility's policies required careful transcription, review, and discontinuation of old orders when new ones were entered, as well as prompt reporting and investigation of medication errors. However, these procedures were not followed, resulting in significant medication errors for both residents. The facility did not conduct timely or documented audits to identify or prevent similar errors, and there was a lack of immediate investigation or staff education following the incidents.
Deficient Food Storage, Labeling, and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe and sanitary manner, as observed during a kitchen inspection. Surveyors found multiple food items intended for resident consumption that were not properly labeled or were past their discard dates, including a tater tot casserole with no use-by date, a gluten-free hot dog bun with no year or use-by date, and an open box of turkey breasts with no use-by date. The Dietary Manager confirmed that these items were past expiration and should have been discarded. These practices were not in accordance with the 2022 FDA Food Code requirements for date marking and safe storage of ready-to-eat, time/temperature control for safety foods. Additionally, the facility did not maintain kitchen equipment in a clean condition or store it properly. Surveyors observed a coffee dispensing machine with dried coffee debris inside, and the cleaning log indicated it had not been cleaned for over two months, despite a policy of weekly cleaning. Three standing mixers, a vertical cutter mixer (VCM), and several VCM disc blades were found uncovered when not in use. The Dietary Manager acknowledged that these items were not covered, which is inconsistent with professional standards for storing clean equipment and utensils to prevent contamination.
Incomplete Investigation of Misappropriation Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation involving a resident, identified as R73, who reported $150 missing from their room. The incident occurred after R73 withdrew money for a shopping trip and refused to have it securely stored. The investigation was incomplete as not all staff who had access to R73's room during the relevant timeframes were interviewed. The facility's policy requires a thorough investigation, including interviewing all potential witnesses and staff who may have been involved. R73, who was not cognitively impaired as indicated by a BIMS score of 15 out of 15, reported the missing money on the day of the shopping trip. The investigation documentation included statements from nine staff members, but four staff who had access to R73's room during the specified shifts were not interviewed. Both the Commandant and the Director of Nursing acknowledged that the investigation did not meet the facility's policy requirements, as not all relevant staff were interviewed.
Call Light Not Within Reach for Resident with Fall Risk
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's dementia, chronic obstructive pulmonary disease, and adult failure to thrive did not have a call light within reach while seated in a recliner. The resident's Minimum Data Set assessment indicated moderately impaired cognition, and the care plan identified a risk for falls with an intervention to remind the resident to call for assistance. On observation, the call light was found wrapped around a trapezius bar above the bed, making it inaccessible to the resident. Both an LPN and the Director of Nursing confirmed that the call light was not within reach, contrary to the facility's policy requiring call lights to be accessible to residents.
Failure to Provide and Document Suprapubic Catheter Site Care
Penalty
Summary
Staff failed to provide appropriate suprapubic catheter site care for a resident with a history of Parkinson's disease, chronic kidney disease, and an atonic bladder requiring a suprapubic urinary catheter. The resident's medical record did not contain any orders or documentation indicating that routine suprapubic catheter site care was provided to prevent urinary tract infections (UTIs), although the catheter was changed monthly as ordered by the physician. The resident reported experiencing frequent UTIs in the past, which had improved more recently. During the survey, staff interviews revealed uncertainty regarding the facility's policy on suprapubic catheter care, and the Director of Nursing (DON) was unable to provide documentation that the required site care was completed. The facility's available policy only referenced cleansing the site during catheter insertion or removal and routine perineal care for Foley catheters, not for suprapubic catheters. Observations and interviews confirmed that there was no evidence of regular suprapubic catheter site care being performed or documented for the resident.
Oxygen Therapy Provided Without Physician Order or Proper Documentation
Penalty
Summary
A resident with diagnoses including chronic diastolic (congestive) heart failure, obstructive sleep apnea, and type 2 diabetes mellitus with diabetic chronic kidney disease was observed receiving oxygen therapy at 6 liters per minute via nasal cannula, connected to an oxygen concentrator. The resident's medical record did not contain a physician order or care plan for oxygen therapy, and the oxygen tubing and humidifier canister in use were not dated as required by facility policy. Staff interviews confirmed that the resident had been using oxygen without a current physician order specifying the dose, route, or pulse oximetry parameters, and that the required documentation and labeling procedures were not followed. The facility's policy mandates a provider's order for extended oxygen use, including specific instructions for administration and equipment maintenance. Despite this, the resident was receiving oxygen therapy without the necessary order or care plan, and the equipment in use was not properly labeled or maintained according to policy. Both the respiratory therapist and the director of nursing acknowledged the absence of required orders and care planning for the resident's oxygen therapy at the time of the survey.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as required for two residents who were on enhanced barrier precautions (EBP) due to the presence of indwelling medical devices. One resident, who had an indwelling urinary catheter and was not cognitively impaired, was observed during catheter care when an LPN emptied the Foley catheter bag without wearing a gown, contrary to the facility's EBP policy. The LPN confirmed awareness of the policy and acknowledged that a gown should have been worn during this high-contact care activity. Similarly, another resident with a gastrostomy tube (G-tube) and no cognitive impairment was observed receiving medication via the G-tube from the same LPN, who again did not wear a gown as required by the EBP policy. The LPN verified that a gown should have been worn during this procedure. The Director of Nursing also confirmed that both residents were on EBP and that gown use was required for these high-contact care activities, as outlined in the facility's policy.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near King
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wi Veterans Hm Ainsworth Hall | 0 mi | ★★★★★ | 0 | 0 |
| Bethany Home | 2.1 mi | ★★★★★ | 2 | 0 |
| Avina Of Weyauwega | 10.1 mi | ★★★★★ | 6 | 0 |
| Manawa Com Nur Ctr | 12.3 mi | ★★★★★ | 0 | 0 |
| St Joseph Residence | 18.9 mi | ★★★★★ | 7 | 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.