Wisconsin Nursing Homes: State Citations Issued from 10/01/2010 to 9/30/2011
Information is current as of 10/24/2011

Facility=DALLAS CARE AND REHAB, DALLAS, WESTERN REGION (CONTACT: Sherry Walters, (715) 836-4420)*

Survey
Exit Date		 Survey Type Wisconsin
Administrative
Code Cited		 Class Code Revisit
Survey Result		 Status
of Appeal++
05/17/2011 COMPLAINT 50.09(1)(L) , "Care " CLASS B DEFICIENCY CORRECTED 06/17/2011 NO APPEAL ON RECORD

*Please direct questions to the Bureau of Nursing Home Resident Care regional contact
noted above after the facility name and location.
++Appeal status is as of the last day of the reporting period, in this case September 30, 2011. Changes in the appeal status
occurring after that date will be noted in the updated Nursing Home State Citations Report generated the following quarter.


Wisconsin Nursing Homes: State Citations Issued from 10/01/2010 to 9/30/2011
Information is current as of 10/24/2011

Facility=DEERFIELD CARE CENTER, LLC, NEW RICHMOND, WESTERN REGION (CONTACT: Sherry Walters, (715) 836-4420)*

Survey
Exit Date		 Survey Type Wisconsin
Administrative
Code Cited		 Class Code Revisit
Survey Result		 Status
of Appeal++
10/21/2010 COMPLAINT 50.09(1)(L) , "Care " CLASS B DEFICIENCY CORRECTED 07/16/2010 NO APPEAL ON RECORD

*Please direct questions to the Bureau of Nursing Home Resident Care regional contact
noted above after the facility name and location.
++Appeal status is as of the last day of the reporting period, in this case September 30, 2011. Changes in the appeal status
occurring after that date will be noted in the updated Nursing Home State Citations Report generated the following quarter.


Wisconsin Nursing Homes: State Citations Issued from 10/01/2010 to 9/30/2011
Information is current as of 10/24/2011

Facility=DUNN CTY HLTH CARE CTR, MENOMONIE, WESTERN REGION (CONTACT: Sherry Walters, (715) 836-4420)*

Survey
Exit Date		 Survey Type Wisconsin
Administrative
Code Cited		 Class Code Revisit
Survey Result		 Status
of Appeal++
01/04/2011 COMPLAINT 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 02/04/2011 DISMISSED

*Please direct questions to the Bureau of Nursing Home Resident Care regional contact
noted above after the facility name and location.
++Appeal status is as of the last day of the reporting period, in this case September 30, 2011. Changes in the appeal status
occurring after that date will be noted in the updated Nursing Home State Citations Report generated the following quarter.


Wisconsin Nursing Homes: State Citations Issued from 10/01/2010 to 9/30/2011
Information is current as of 10/24/2011

Facility=EASTSIDE HEALTH AND REHAB CTR, MILWAUKEE, SOUTHEAST REGION (CONTACT: Carol Jean Rucker, (414) 227-4563)*

Survey
Exit Date		 Survey Type Wisconsin
Administrative
Code Cited		 Class Code Revisit
Survey Result		 Status
of Appeal++
12/14/2010 COMPLAINT 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " CLASS B DEFICIENCY CORRECTED 01/13/2011 NO APPEAL ON RECORD
04/06/2011 COMPLAINT 132.60(1)(b) , "RESIDENT CARE/DECUBITI PREVENTION " CLASS B DEFICIENCY CORRECTED 05/03/2011 NO APPEAL ON RECORD
04/06/2011 COMPLAINT 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 05/03/2011 NO APPEAL ON RECORD
06/09/2011 FULL/COMPLAINT 132.60(5)(a)1 , "RESIDENT CARE/ORDERS " CLASS C DEFICIENCY -- CORRECTION ORDER SERVED CORRECTED 07/08/2011 NO APPEAL ON RECORD
08/19/2011 COMPLAINT 132.41(1) , "ADMINISTRATOR " CLASS B DEFICIENCY CORRECTED 09/18/2011 NO APPEAL ON RECORD
08/19/2011 COMPLAINT 132.60(1)(b) , "RESIDENT CARE/DECUBITI PREVENTION " MULTIPLE CLASS 'B' OR 'A' DEFICIENCIES CORRECTED 09/18/2011 NO APPEAL ON RECORD
08/19/2011 COMPLAINT 132.60(3)(a) , "RESIDENT CARE/NOTIFICATION OF CHANGE " CLASS B DEFICIENCY CORRECTED 09/18/2011 NO APPEAL ON RECORD
08/19/2011 COMPLAINT 132.60(5)(a)1 , "RESIDENT CARE/ORDERS " CLASS B DEFICIENCY CORRECTED 09/18/2011 NO APPEAL ON RECORD

*Please direct questions to the Bureau of Nursing Home Resident Care regional contact
noted above after the facility name and location.
++Appeal status is as of the last day of the reporting period, in this case September 30, 2011. Changes in the appeal status
occurring after that date will be noted in the updated Nursing Home State Citations Report generated the following quarter.


Wisconsin Nursing Homes: State Citations Issued from 10/01/2010 to 9/30/2011
Information is current as of 10/24/2011

Facility=EDGEWATER HAVEN NUR HOME, PORT EDWARDS, NORTHERN REGION (CONTACT: Jessica Radtke, (715) 365-2801)*

Survey
Exit Date		 Survey Type Wisconsin
Administrative
Code Cited		 Class Code Revisit
Survey Result		 Status
of Appeal++
08/23/2011 COMPLAINT 50.09(1)(e) , "Treatment " CLASS B DEFICIENCY   NO APPEAL ON RECORD

*Please direct questions to the Bureau of Nursing Home Resident Care regional contact
noted above after the facility name and location.
++Appeal status is as of the last day of the reporting period, in this case September 30, 2011. Changes in the appeal status
occurring after that date will be noted in the updated Nursing Home State Citations Report generated the following quarter.


Wisconsin Nursing Homes: State Citations Issued from 10/01/2010 to 9/30/2011
Information is current as of 10/24/2011

Facility=ELLSWORTH CARE CTR, ELLSWORTH, WESTERN REGION (CONTACT: Sherry Walters, (715) 836-4420)*

Survey
Exit Date		 Survey Type Wisconsin
Administrative
Code Cited		 Class Code Revisit
Survey Result		 Status
of Appeal++
02/15/2011 FULL/COMPLAINT 132.62(2)(a)3.f , "DON/DEFINING NRSG ROLES " CLASS C DEFICIENCY -- CORRECTION ORDER SERVED CORRECTED 03/15/2011 NO APPEAL ON RECORD

*Please direct questions to the Bureau of Nursing Home Resident Care regional contact
noted above after the facility name and location.
++Appeal status is as of the last day of the reporting period, in this case September 30, 2011. Changes in the appeal status
occurring after that date will be noted in the updated Nursing Home State Citations Report generated the following quarter.


Wisconsin Nursing Homes: State Citations Issued from 10/01/2010 to 9/30/2011
Information is current as of 10/24/2011

Facility=EVERGREEN CARE CTR, SHAWANO, NORTHEAST REGION (CONTACT: Dolores Zwiers, (920) 983-3185)*

Survey
Exit Date		 Survey Type Wisconsin
Administrative
Code Cited		 Class Code Revisit
Survey Result		 Status
of Appeal++
03/29/2011 FULL/COMPLAINT 132.60(1)(b) , "RESIDENT CARE/DECUBITI PREVENTION " CLASS B DEFICIENCY CORRECTED 04/29/2011 APPEALED: 04/25/2011
03/29/2011 FULL/COMPLAINT 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 04/29/2011 APPEALED: 04/25/2011

*Please direct questions to the Bureau of Nursing Home Resident Care regional contact
noted above after the facility name and location.
++Appeal status is as of the last day of the reporting period, in this case September 30, 2011. Changes in the appeal status
occurring after that date will be noted in the updated Nursing Home State Citations Report generated the following quarter.


Wisconsin Nursing Homes: State Citations Issued from 10/01/2010 to 9/30/2011
Information is current as of 10/24/2011

Facility=EVERGREEN HEALTH CENTER, OSHKOSH, NORTHEAST REGION (CONTACT: Dolores Zwiers, (920) 983-3185)*

Survey
Exit Date		 Survey Type Wisconsin
Administrative
Code Cited		 Class Code Revisit
Survey Result		 Status
of Appeal++
01/18/2011 FULL 132.60(8)(b) , "UPDATING OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 02/18/2011 NO APPEAL ON RECORD

*Please direct questions to the Bureau of Nursing Home Resident Care regional contact
noted above after the facility name and location.
++Appeal status is as of the last day of the reporting period, in this case September 30, 2011. Changes in the appeal status
occurring after that date will be noted in the updated Nursing Home State Citations Report generated the following quarter.


Wisconsin Nursing Homes: State Citations Issued from 10/01/2010 to 9/30/2011
Information is current as of 10/24/2011

Facility=FOND DU LAC LUTH HOME, FOND DU LAC, NORTHEAST REGION (CONTACT: Dolores Zwiers, (920) 983-3185)*

Survey
Exit Date		 Survey Type Wisconsin
Administrative
Code Cited		 Class Code Revisit
Survey Result		 Status
of Appeal++
05/19/2011 COMPLAINT 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " CLASS B DEFICIENCY CORRECTED 06/17/2011 APPEALED: 06/10/2011

*Please direct questions to the Bureau of Nursing Home Resident Care regional contact
noted above after the facility name and location.
++Appeal status is as of the last day of the reporting period, in this case September 30, 2011. Changes in the appeal status
occurring after that date will be noted in the updated Nursing Home State Citations Report generated the following quarter.


Wisconsin Nursing Homes: State Citations Issued from 10/01/2010 to 9/30/2011
Information is current as of 10/24/2011

Facility=FOUNTAIN VIEW CARE CTR, RIPON, NORTHEAST REGION (CONTACT: Dolores Zwiers, (920) 983-3185)*

Survey
Exit Date		 Survey Type Wisconsin
Administrative
Code Cited		 Class Code Revisit
Survey Result		 Status
of Appeal++
11/04/2010 COMPLAINT 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " CLASS B DEFICIENCY CORRECTED 11/24/2010 DISMISSED
11/04/2010 COMPLAINT 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 11/24/2010 DISMISSED
05/05/2011 FULL 132.51(2)(b) , "ADMISSIONS/COMMUNICABLE DISEASE " CLASS B DEFICIENCY CORRECTED 05/27/2011 APPEALED: 05/18/2011
05/05/2011 FULL 132.60(8)(b) , "UPDATING OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 05/27/2011 APPEALED: 05/18/2011

*Please direct questions to the Bureau of Nursing Home Resident Care regional contact
noted above after the facility name and location.
++Appeal status is as of the last day of the reporting period, in this case September 30, 2011. Changes in the appeal status
occurring after that date will be noted in the updated Nursing Home State Citations Report generated the following quarter.


Wisconsin Nursing Homes: State Citations Issued from 10/01/2010 to 9/30/2011
Information is current as of 10/24/2011

Facility=FOUR WINDS MANOR, VERONA, SOUTHERN REGION (CONTACT: Kristy Pecosky, (608) 266-8633)*

Survey
Exit Date		 Survey Type Wisconsin
Administrative
Code Cited		 Class Code Revisit
Survey Result		 Status
of Appeal++
10/26/2010 REVISIT 132.60(1)(c)4 , "RESIDENT CARE/BASIC NRSG CARE " CLASS B DEFICIENCY CORRECTED 11/11/2010 NO APPEAL ON RECORD
10/26/2010 REVISIT 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 11/11/2010 NO APPEAL ON RECORD

*Please direct questions to the Bureau of Nursing Home Resident Care regional contact
noted above after the facility name and location.
++Appeal status is as of the last day of the reporting period, in this case September 30, 2011. Changes in the appeal status
occurring after that date will be noted in the updated Nursing Home State Citations Report generated the following quarter.


Wisconsin Nursing Homes: State Citations Issued from 10/01/2010 to 9/30/2011
Information is current as of 10/24/2011

Facility=FRANCISCAN VILLA, SOUTH MILWAUKEE, SOUTHEAST REGION (CONTACT: Carol Jean Rucker, (414) 227-4563)*

Survey
Exit Date		 Survey Type Wisconsin
Administrative
Code Cited		 Class Code Revisit
Survey Result		 Status
of Appeal++
03/03/2011 COMPLAINT 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " CLASS B DEFICIENCY CORRECTED 04/02/2011 NO APPEAL ON RECORD

*Please direct questions to the Bureau of Nursing Home Resident Care regional contact
noted above after the facility name and location.
++Appeal status is as of the last day of the reporting period, in this case September 30, 2011. Changes in the appeal status
occurring after that date will be noted in the updated Nursing Home State Citations Report generated the following quarter.


Wisconsin Nursing Homes: State Citations Issued from 10/01/2010 to 9/30/2011
Information is current as of 10/24/2011

Facility=FREDERIC NUR REHAB COM, FREDERIC, WESTERN REGION (CONTACT: Sherry Walters, (715) 836-4420)*

Survey
Exit Date		 Survey Type Wisconsin
Administrative
Code Cited		 Class Code Revisit
Survey Result		 Status
of Appeal++
08/11/2011 FULL 132.60(1)(c)5 , "FACILITY SHALL PROVIDE PAIN ASSESSMNT/TREATMT" CLASS B DEFICIENCY CORRECTED 09/02/2011 NO APPEAL ON RECORD

*Please direct questions to the Bureau of Nursing Home Resident Care regional contact
noted above after the facility name and location.
++Appeal status is as of the last day of the reporting period, in this case September 30, 2011. Changes in the appeal status
occurring after that date will be noted in the updated Nursing Home State Citations Report generated the following quarter.


Wisconsin Nursing Homes: State Citations Issued from 10/01/2010 to 9/30/2011
Information is current as of 10/24/2011

Facility=FRIENDLY VILLAGE NURSING AND REHAB CENTER, RHINELANDER, NORTHERN REGION (CONTACT: Jessica Radtke, (715) 365-2801)*

Survey
Exit Date		 Survey Type Wisconsin
Administrative
Code Cited		 Class Code Revisit
Survey Result		 Status
of Appeal++
11/30/2010 COMPLAINT 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " CLASS B DEFICIENCY CORRECTED 12/08/2010 NO APPEAL ON RECORD

*Please direct questions to the Bureau of Nursing Home Resident Care regional contact
noted above after the facility name and location.
++Appeal status is as of the last day of the reporting period, in this case September 30, 2011. Changes in the appeal status
occurring after that date will be noted in the updated Nursing Home State Citations Report generated the following quarter.