The Vardell Report.Rock River Nursing & Rehab

Across 14 inspections from October 2023 to May 2026, state surveyors documented 115 findings at Rock River Nursing & Rehab; 115 have a recorded correction; CMS lists 4 enforcement actions in the window.

Inspections

14

2023–2026, standard and complaint

Findings

115

Deficiencies cited by state inspectors

Corrected

115

Of 115 findings, with a recorded correction date

Penalties

4

2 fines; payment not published, 2 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. May 62026

   Standard health inspection

   7 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jun 4, 2026
   • F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected Jun 4, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jun 4, 2026
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Jun 4, 2026
   • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Jun 4, 2026
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Jun 4, 2026
   • F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Jun 4, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Feb 62026

   Complaint investigation

   1 finding

   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Mar 10, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Dec 42025

   Standard health inspection

   3 findings

   The same visit included a complaint investigation.

   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jan 13, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jan 13, 2026
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Jan 13, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Jul 232025

   Complaint investigation

   7 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level KImmediate jeopardyCorrected Aug 28, 2025
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level ENo actual harm, potential for moreCorrected Aug 28, 2025
   • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Aug 28, 2025
   • F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level DNo actual harm, potential for moreCorrected Aug 28, 2025
   • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level DNo actual harm, potential for moreCorrected Aug 28, 2025
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level DNo actual harm, potential for moreCorrected Aug 28, 2025
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Aug 28, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Apr 172025

   Standard health inspection

   14 findings

   The same visit included a complaint investigation.

   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected May 23, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected May 23, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected May 23, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected May 23, 2025
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected May 23, 2025
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected May 23, 2025
   • F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level FNo actual harm, potential for moreCorrected May 23, 2025
   • F926Have policies on smoking.Level ENo actual harm, potential for moreCorrected May 23, 2025
   • F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level DNo actual harm, potential for moreCorrected May 23, 2025
   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected May 23, 2025
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected May 23, 2025
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected May 23, 2025
   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected May 23, 2025
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected May 23, 2025

   Enforcement Action

   Civil money penalty, $91,960 imposed July 23, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 17, 2025, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed July 23, 2025. Status: Closed, August 28, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 17, 2025, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Jan 152025

   Complaint investigation

   18 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected May 23, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level JImmediate jeopardyCorrected Feb 13, 2025
   • F730Observe each nurse aide's job performance and give regular training.Level FNo actual harm, potential for moreCorrected Feb 13, 2025
   • F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.Level FNo actual harm, potential for moreCorrected Feb 13, 2025
   • F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level FNo actual harm, potential for moreCorrected Feb 13, 2025
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level FNo actual harm, potential for moreCorrected Feb 13, 2025
   • F946Provide training in compliance and ethics.Level FNo actual harm, potential for moreCorrected Feb 13, 2025
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level FNo actual harm, potential for moreCorrected Feb 13, 2025
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Feb 13, 2025
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
   • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
   • F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
   • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
   • F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Level DNo actual harm, potential for moreCorrected Feb 13, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Sep 112024

   Complaint investigation

   23 findings

   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Oct 18, 2024
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Oct 18, 2024
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Oct 18, 2024
   • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level ENo actual harm, potential for moreCorrected Oct 18, 2024
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Oct 18, 2024
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F563Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F699Provide care or services that was trauma informed and/or culturally competent.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
   • F814Dispose of garbage and refuse properly.Level CPotential for minimal harmCorrected Oct 18, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Jul 242024

   Complaint investigation

   1 finding

   • F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.Level FNo actual harm, potential for moreCorrected Aug 15, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. Jun 122024

   Complaint investigation

   7 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Oct 21, 2024
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jul 16, 2024
   • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Jul 16, 2024
   • F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Jul 16, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 16, 2024
   • F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Jul 16, 2024
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 16, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

10. Apr 252024

    Complaint investigation

    7 findings

    • F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level JImmediate jeopardyCorrected Apr 9, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Oct 21, 2024
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected May 23, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected May 23, 2024
    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected May 23, 2024
    • F807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.Level DNo actual harm, potential for moreCorrected May 23, 2024
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 16, 2024

    Enforcement Action

    Civil money penalty, $119,141 imposed April 25, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the complaint investigation of April 25, 2024, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed April 25, 2024. Status: Closed, October 21, 2024. CMS does not tie a penalty to a survey; listed with the complaint investigation of April 25, 2024, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

11. Mar 72024

    Complaint investigation

    2 findings

    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 19, 2024
    • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 19, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

12. Feb 212024

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Mar 12, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

13. Dec 122023

    Complaint investigation

    6 findings

    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jan 12, 2024
    • F572Give residents a notice of rights, rules, services and charges.Level ENo actual harm, potential for moreCorrected Jan 12, 2024
    • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
    • F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Mar 12, 2024
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Jan 12, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

14. Oct 162023

    Complaint investigation

    18 findings

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Mar 12, 2024
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level FNo actual harm, potential for moreCorrected Nov 10, 2023
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Nov 10, 2023
    • F814Dispose of garbage and refuse properly.Level FNo actual harm, potential for moreCorrected Nov 10, 2023
    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Nov 10, 2023
    • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level ENo actual harm, potential for moreCorrected Nov 10, 2023
    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Nov 10, 2023
    • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Nov 10, 2023
    • F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level ENo actual harm, potential for moreCorrected Nov 10, 2023
    • F825Provide or get specialized rehabilitative services as required for a resident.Level ENo actual harm, potential for moreCorrected Nov 10, 2023
    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Nov 10, 2023
    • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Nov 10, 2023
    • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Nov 10, 2023
    • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Nov 10, 2023
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 10, 2023
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Nov 10, 2023
    • F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Level DNo actual harm, potential for moreCorrected Nov 10, 2023
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Nov 10, 2023

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Accident Hazards and Supervision, Cited in Seven Inspections

   Inspectors cited F689 in October 2023, December 2023, September 2024, January 2025, April 2025, July 2025 and May 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2323242424242424252525252626F689 across all 14 inspections, oldest to newest
2. 2

   Quality of Care, Cited in Six Inspections

   Inspectors cited F684 in October 2023, February 2024, June 2024, September 2024, January 2025 and April 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2323242424242424252525252626F684 across all 14 inspections, oldest to newest
3. 3

   Infection Control, Cited in Five Inspections

   Inspectors cited F880 in October 2023, April 2024, June 2024, September 2024 and April 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2323242424242424252525252626F880 across all 14 inspections, oldest to newest
4. 4

   Telling Families About Changes, Cited in Four Inspections

   Inspectors cited F580 in December 2023, June 2024, September 2024 and January 2025. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2323242424242424252525252626F580 across all 14 inspections, oldest to newest
5. 5

   Investigating Alleged Violations, Cited in Four Inspections

   Inspectors cited F610 in April 2024, January 2025, April 2025 and December 2025. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2323242424242424252525252626F610 across all 14 inspections, oldest to newest
6. 6

   Pressure Injury Care, Cited in Four Inspections

   Inspectors cited F686 in April 2024, June 2024, April 2025 and May 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2323242424242424252525252626F686 across all 14 inspections, oldest to newest
7. 7

   A Clean, Homelike Setting, Cited in Three Inspections

   Inspectors cited F584 in October 2023, September 2024 and January 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2323242424242424252525252626F584 across all 14 inspections, oldest to newest
8. 8

   Nursing Staff Levels, Cited in Three Inspections

   Inspectors cited F725 in October 2023, September 2024 and April 2025. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2323242424242424252525252626F725 across all 14 inspections, oldest to newest
9. 9

   Pharmacy Services, Cited in Three Inspections

   Inspectors cited F755 in April 2024, September 2024 and January 2025. This citation covers pharmacy services and the licensed pharmacist who oversees them. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2323242424242424252525252626F755 across all 14 inspections, oldest to newest
10. 10

    Medication Error Rate, Cited in Three Inspections

    Inspectors cited F759 in October 2023, September 2024 and January 2025. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F759 across all 14 inspections, oldest to newest
11. 11

    Food Quality and Temperature, Cited in Three Inspections

    Inspectors cited F804 in October 2023, December 2023 and May 2026. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F804 across all 14 inspections, oldest to newest
12. 12

    Kitchen and Food Safety, Cited in Three Inspections

    Inspectors cited F812 in October 2023, December 2023 and April 2024. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F812 across all 14 inspections, oldest to newest
13. 13

    Citation F553, Cited in Two Inspections

    Inspectors cited F553 in September 2024 and April 2025. The agency describes it this way: Allow resident to participate in the development and implementation of his or her person-centered plan of care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F553 across all 14 inspections, oldest to newest
14. 14

    Grievances, Cited in Two Inspections

    Inspectors cited F585 in October 2023 and June 2024. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F585 across all 14 inspections, oldest to newest
15. 15

    Citation F604, Cited in Two Inspections

    Inspectors cited F604 in October 2023 and April 2025. The agency describes it this way: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F604 across all 14 inspections, oldest to newest
16. 16

    Citation F660, Cited in Two Inspections

    Inspectors cited F660 in June 2024 and September 2024. The agency describes it this way: Plan the resident's discharge to meet the resident's goals and needs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F660 across all 14 inspections, oldest to newest
17. 17

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in March 2024 and September 2024. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F677 across all 14 inspections, oldest to newest
18. 18

    Citation F678, Cited in Two Inspections

    Inspectors cited F678 in December 2023 and April 2024. The agency describes it this way: Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F678 across all 14 inspections, oldest to newest
19. 19

    Citation F726, Cited in Two Inspections

    Inspectors cited F726 in September 2024 and January 2025. The agency describes it this way: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F726 across all 14 inspections, oldest to newest
20. 20

    Citation F745, Cited in Two Inspections

    Inspectors cited F745 in September 2024 and July 2025. The agency describes it this way: Provide medically-related social services to help each resident achieve the highest possible quality of life. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F745 across all 14 inspections, oldest to newest
21. 21

    Citation F757, Cited in Two Inspections

    Inspectors cited F757 in April 2025 and May 2026. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F757 across all 14 inspections, oldest to newest
22. 22

    Psychotropic Medications, Cited in Two Inspections

    Inspectors cited F758 in September 2024 and April 2025. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F758 across all 14 inspections, oldest to newest
23. 23

    Garbage and Refuse, Cited in Two Inspections

    Inspectors cited F814 in October 2023 and September 2024. This citation covers whether garbage and refuse are disposed of properly. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F814 across all 14 inspections, oldest to newest
24. 24

    Citation F837, Cited in Two Inspections

    Inspectors cited F837 in July 2024 and January 2025. The agency describes it this way: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F837 across all 14 inspections, oldest to newest
25. 25

    Citation F942, Cited in Two Inspections

    Inspectors cited F942 in January 2025 and July 2025. The agency describes it this way: Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F942 across all 14 inspections, oldest to newest
26. 26

    Citation F943, Cited in Two Inspections

    Inspectors cited F943 in January 2025 and July 2025. The agency describes it this way: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F943 across all 14 inspections, oldest to newest
27. 27

    Citation F944, Cited in Two Inspections

    Inspectors cited F944 in January 2025 and July 2025. The agency describes it this way: Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F944 across all 14 inspections, oldest to newest
28. 28

    Citation F949, Cited in Two Inspections

    Inspectors cited F949 in January 2025 and July 2025. The agency describes it this way: Provide behavior health training consistent with the requirements and as determined by a facility assessment. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323242424242424252525252626F949 across all 14 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in seven inspections, most seriously at level K.

2. 02

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in six inspections, most seriously at level J.

3. 03

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in five inspections, most seriously at level F.

4. 04

   How quickly will we hear about a fall, an injury or a change in condition, and from whom?

   Telling Families About Changes: cited in four inspections, most seriously at level D.

5. 05

   When an allegation is made, who investigates it, and how are residents protected in the meantime?

   Investigating Alleged Violations: cited in four inspections, most seriously at level D.

6. 06

   How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in four inspections, most seriously at level G.

7. 07

   What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

   A Clean, Homelike Setting: cited in three inspections, most seriously at level E.

8. 08

   How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

   Nursing Staff Levels: cited in three inspections, most seriously at level F.

9. 09

   How often does the consultant pharmacist review each resident’s medications?

   Pharmacy Services: cited in three inspections, most seriously at level J.

10. 10

    How are medication passes checked, and what happens when an error is found?

    Medication Error Rate: cited in three inspections, most seriously at level E.

11. 11

    May we try a meal, and how do you check food temperature by the time it reaches residents?

    Food Quality and Temperature: cited in three inspections, most seriously at level F.

12. 12

    May we see the kitchen, and what do your own sanitation checks look like week to week?

    Kitchen and Food Safety: cited in three inspections, most seriously at level F.

13. 13

    What changed after F553 was cited, and how do you check it now?

    Citation F553: cited in two inspections, most seriously at level D.

14. 14

    How do we file a grievance, who answers it, and how quickly?

    Grievances: cited in two inspections, most seriously at level E.

15. 15

    What changed after F604 was cited, and how do you check it now?

    Citation F604: cited in two inspections, most seriously at level D.

16. 16

    What changed after F660 was cited, and how do you check it now?

    Citation F660: cited in two inspections, most seriously at level D.

17. 17

    How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

    Help With Daily Living: cited in two inspections, most seriously at level D.

18. 18

    What changed after F678 was cited, and how do you check it now?

    Citation F678: cited in two inspections, most seriously at level J.

19. 19

    What changed after F726 was cited, and how do you check it now?

    Citation F726: cited in two inspections, most seriously at level E.

20. 20

    What changed after F745 was cited, and how do you check it now?

    Citation F745: cited in two inspections, most seriously at level D.

21. 21

    What changed after F757 was cited, and how do you check it now?

    Citation F757: cited in two inspections, most seriously at level D.

22. 22

    How many residents take psychotropic medications, and how often are doses reviewed for reduction?

    Psychotropic Medications: cited in two inspections, most seriously at level D.

23. 23

    How is waste handled around the kitchen and resident areas?

    Garbage and Refuse: cited in two inspections, most seriously at level F.

24. 24

    What changed after F837 was cited, and how do you check it now?

    Citation F837: cited in two inspections, most seriously at level F.

25. 25

    What changed after F942 was cited, and how do you check it now?

    Citation F942: cited in two inspections, most seriously at level D.

26. 26

    What changed after F943 was cited, and how do you check it now?

    Citation F943: cited in two inspections, most seriously at level D.

27. 27

    What changed after F944 was cited, and how do you check it now?

    Citation F944: cited in two inspections, most seriously at level F.

28. 28

    What changed after F949 was cited, and how do you check it now?

    Citation F949: cited in two inspections, most seriously at level F.

29. 29

    What led to the 2025 fine, and has it been paid?

    A $91,960 civil money penalty was imposed July 23, 2025. CMS publishes the fine, not whether it has been paid. The record holds four enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Wisconsin state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Oct 16, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Dec 12, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Feb 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Mar 7, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Apr 25, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Jun 12, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Jul 24, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Sep 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Jan 15, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Apr 17, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Jul 23, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Dec 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Feb 6, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection May 6, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 525262

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.