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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J3 | K· | L· |
| Actual harm | G3 | H· | I· |
| Potential harm | D61 | E24 | F22 |
| Minimal | A· | B· | C1 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Oct 13, 2025 | Fire safety | Fire Safety Standard | 18 | Potential harm | — | Open → |
| Oct 13, 2025 | Health | Health Standard | 15 | Immediate jeopardy | — | Open → |
| Sep 15, 2025 | Health | Health Complaint | 8 | Actual harm | — | Open → |
| Aug 13, 2025 | Health | Health Complaint | 11 | Potential harm | — | Open → |
| Jul 9, 2025 | Health | Health Complaint | 9 | Immediate jeopardy | — | Open → |
| Jun 10, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Mar 14, 2025 | Health | Health Complaint | 5 | Potential harm | — | Open → |
| Jul 11, 2024 | Fire safety | Fire Safety Standard | 11 | Potential harm | — | Open → |
| Jul 11, 2024 | Health | Health Standard | 15 | Actual harm | — | Open → |
| Nov 1, 2023 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Mar 30, 2023 | Fire safety | Fire Safety Standard | 11 | Potential harm | — | Open → |
| Mar 30, 2023 | Health | Health Standard | 9 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Oct 13, 2025 | Denial of payment for new admissions | — | Nov 11, 2025 · 35 days | 525331|Payment Denial|2025-11-11 |
| Oct 13, 2025 | Civil money penalty (fine) | $83,597 | — | 525331|Fine|137573 |
| Jun 10, 2025 | Denial of payment for new admissions | — | Aug 7, 2025 · 68 days | 525331|Payment Denial|2025-08-07 |
| Jun 10, 2025 | Civil money penalty (fine) | $83,656 | — | 525331|Fine|138717 |
| Jun 10, 2025 | Civil money penalty (fine) | $13,273 | — | 525331|Fine|138716 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J3 | K· | L· |
| Actual harm | G3 | H· | I· |
| Potential harm | D61 | E24 | F22 |
| Minimal | A· | B· | C1 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Oct 13, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected Dec 16, 2025 | |
| Oct 13, 2025 | E-0013 | Develop Emergency Preparedness policies and procedures. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Nov 10, 2025 | |
| Oct 13, 2025 | E-0039 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.43 (case-mix index 1.39).
CMS legal business name of the certified provider. Operates 7 facilities.
7 facilities in 2 states. CMS chain ID 569.
Chain average overall rating (CMS): 1.8
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Carriage Healthcare Companies Inc | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 9, 2012 |
| Matthew Paszczak | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 5, 2023 |
| Stephanie Sherman | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 12, 2012 |
| Lori Dupont | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 25, 2016 |
| Miriam Gehler | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2017 |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Fair Oaks Health Care Center 471 Terra Cotta Avenue, Crystal Lake, IL 60014 CCN 145917 | 51 | Feb 2, 2026 | 602 harm | $20k | |
| Edgerton Care Center, Inc 313 Stoughton Rd., Edgerton, WI 53534 CCN 525241 |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Edgerton Care Center, Inc 313 Stoughton Rd., Edgerton, WI 53534 CCN 525241Abuse icon | 61 | Jun 18, 2026 | 801 IJ3 harm | $219k | |
| Holton Manor |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Four Winds Manor 303 S. Jefferson St., Verona, WI 53593 CCN 525656 | 16.3 km | 44 | Jul 23, 2026 | 541 harm | — | |
| Badger Prairie Hcc 1100 E Verona Ave, Verona, WI 53593 CCN 525516 | 16.8 km | 120 | Sep 10, 2025 | 16 | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 525331 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 525331 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Jul 11, 2024 | Civil money penalty (fine) | $36,946 | — | 525331|Fine|61180 |
| Nov 1, 2023 | Civil money penalty (fine) | $13,397 | — | 525331|Fine|61026 |
| Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness |
| F · Potential harm Widespread |
| Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0331 | Construct fire resistant interior walls. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 17, 2025 |
| Oct 13, 2025 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0912 | Have power receptacles that are properly grounded. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Oct 13, 2025 | F-0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Oct 13, 2025 | F-0584 | Honor 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Oct 13, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Oct 13, 2025 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | F-0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | F-0849 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Nov 10, 2025 |
| Oct 13, 2025 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Oct 13, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Nov 10, 2025 |
| Sep 15, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Oct 14, 2025 | Complaint |
| Sep 15, 2025 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 14, 2025 | Complaint |
| Sep 15, 2025 | F-0584 | Honor 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Oct 14, 2025 | Complaint |
| Sep 15, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 14, 2025 | Complaint |
| Sep 15, 2025 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 14, 2025 | Complaint |
| Sep 15, 2025 | F-0740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 14, 2025 | Complaint |
| Sep 15, 2025 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Oct 14, 2025 | Complaint |
| Sep 15, 2025 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Oct 14, 2025 | Complaint |
| Aug 13, 2025 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 7, 2025 | Complaint |
| Aug 13, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 7, 2025 | Complaint |
| Aug 13, 2025 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 7, 2025 | Complaint |
| Aug 13, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 14, 2025 | Complaint |
| Aug 13, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 7, 2025 | Complaint |
| Aug 13, 2025 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 7, 2025 | Complaint |
| Aug 13, 2025 | F-0712 | Ensure that the resident and his/her doctor meet face-to-face at all required visits. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Sep 7, 2025 | Complaint |
| Aug 13, 2025 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Sep 7, 2025 | Complaint |
| Aug 13, 2025 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Sep 7, 2025 | Complaint |
| Aug 13, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Sep 7, 2025 | Complaint |
| Aug 13, 2025 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 7, 2025 | Complaint |
| Jul 9, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected Aug 6, 2025 | Complaint |
| Jul 9, 2025 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected Aug 6, 2025 | Complaint |
| Jul 9, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 6, 2025 | Complaint |
| Jul 9, 2025 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 6, 2025 | Complaint |
| Jul 9, 2025 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | F · Potential harm Widespread | Corrected Aug 6, 2025 | Complaint |
| Jul 9, 2025 | F-0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 6, 2025 | Complaint |
| Jul 9, 2025 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Aug 6, 2025 | Complaint |
| Jul 9, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 6, 2025 | Complaint |
| Jul 9, 2025 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Aug 6, 2025 | Complaint |
| Jun 10, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 6, 2025 | Complaint |
| Mar 14, 2025 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 14, 2025 | Complaint |
| Mar 14, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 14, 2025 | Complaint |
| Mar 14, 2025 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 14, 2025 | Complaint |
| Mar 14, 2025 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Apr 14, 2025 | Complaint |
| Mar 14, 2025 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Apr 14, 2025 | Complaint |
| Jul 11, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Aug 5, 2024 |
| Jul 11, 2024 | K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. Construction Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 5, 2024 |
| Jul 11, 2024 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 5, 2024 |
| Jul 11, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 5, 2024 |
| Jul 11, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 5, 2024 |
| Jul 11, 2024 | K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 5, 2024 |
| Jul 11, 2024 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 5, 2024 |
| Jul 11, 2024 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 5, 2024 |
| Jul 11, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 5, 2024 |
| Jul 11, 2024 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 5, 2024 |
| Jul 11, 2024 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 5, 2024 |
| Jul 11, 2024 | K-0911 | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 5, 2024 |
| Jul 11, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 5, 2024 |
| Jul 11, 2024 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 5, 2024 |
| Jul 11, 2024 | F-0584 | Honor 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 5, 2024 |
| Jul 11, 2024 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 5, 2024 |
| Jul 11, 2024 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 5, 2024 |
| Jul 11, 2024 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 5, 2024 |
| Jul 11, 2024 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Aug 5, 2024 |
| Jul 11, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Aug 5, 2024 |
| Jul 11, 2024 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Aug 5, 2024 |
| Jul 11, 2024 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Aug 5, 2024 |
| Jul 11, 2024 | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Aug 5, 2024 |
| Jul 11, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Aug 5, 2024 |
| Jul 11, 2024 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Aug 5, 2024 |
| Nov 1, 2023 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Nov 27, 2023 | Complaint |
| Mar 30, 2023 | E-0013 | Develop Emergency Preparedness policies and procedures. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected May 5, 2023 |
| Mar 30, 2023 | K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 5, 2023 |
| Mar 30, 2023 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 5, 2023 |
| Mar 30, 2023 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 5, 2023 |
| Mar 30, 2023 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 5, 2023 |
| Mar 30, 2023 | K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 5, 2023 |
| Mar 30, 2023 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 5, 2023 |
| Mar 30, 2023 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 5, 2023 |
| Mar 30, 2023 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 5, 2023 |
| Mar 30, 2023 | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 5, 2023 |
| Mar 30, 2023 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 26, 2023 |
| Mar 30, 2023 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 5, 2023 |
| Mar 30, 2023 | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 5, 2023 |
| Mar 30, 2023 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 5, 2023 |
| Mar 30, 2023 | F-0585 | Honor 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 5, 2023 |
| Mar 30, 2023 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 5, 2023 |
| Mar 30, 2023 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 5, 2023 |
| Mar 30, 2023 | F-0809 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected May 5, 2023 |
| Mar 30, 2023 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected May 5, 2023 |
| Mar 30, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Apr 28, 2023 |
| Andrew Kerwin | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jun 26, 2009 |
| Rajeev Shiva Kumar | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Apr 24, 2012 |
| Karen Lacke (Carrig) | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2016 |
| Nicholas Lynn | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Mar 14, 2011 |
| Carriage Healthcare Companies Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Oct 6, 2025 |
| Hbt It LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jul 1, 2024 |
| Jt and Associates LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2010 |
| Partners in Wealth Management, Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2024 |
| Pinion, LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 1995 |
| Rehab Solutions Group, LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2024 |
| Twomagnets LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2022 |
| Matthew Paszczak | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 5, 2023 |
| Stephanie Sherman | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 12, 2012 |
| 61 |
| Jun 18, 2026 |
801 IJ3 harm |
| $219k |
| Holton Manor 645 N Church St, Elkhorn, WI 53121 CCN 525541 | 60 | May 6, 2026 | 343 harm | — |
| East Troy Manor 3271 North St, East Troy, WI 53120 CCN 525561 | 50 | Jan 8, 2026 | 583 IJ1 harm | $129k |
| Geneva Lake Manor 211 S. Curtis St., Lake Geneva, WI 53147 CCN 525565 | 60 | Aug 10, 2026 | 1023 IJ3 harm3 open | $131k |
| Montello Care Center 251 Forest Lane, Montello, WI 53949 CCN 525657 | 50 | Aug 5, 2026 | 1042 IJ2 harm1 open | $143k |
| 60 |
| May 6, 2026 |
343 harm |
| — |
| East Troy Manor 3271 North St, East Troy, WI 53120 CCN 525561 | 50 | Jan 8, 2026 | 583 IJ1 harm | $129k |
| Geneva Lake Manor 211 S. Curtis St., Lake Geneva, WI 53147 CCN 525565 | 60 | Aug 10, 2026 | 1023 IJ3 harm3 open | $131k |
| Montello Care Center 251 Forest Lane, Montello, WI 53949 CCN 525657 | 50 | Aug 5, 2026 | 1042 IJ2 harm1 open | $143k |