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

Facility=GENEVA LAKE MANOR, LAKE GENEVA, 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++
05/20/2011 FULL 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 06/20/2011 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=GILMAN CARE CENTER, LLC, GILMAN, 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++
09/15/2011 FULL 50.065(2)(bm) , "OUT OF STATE BACKGROUND CHECKS " CLASS C DEFICIENCY -- CORRECTION ORDER SERVED   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=GLENHAVEN, GLENWOOD CITY, 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++
02/03/2011 COMPLAINT 132.51(2)(b) , "ADMISSIONS/COMMUNICABLE DISEASE " CLASS B DEFICIENCY CORRECTED 03/18/2011 APPEALED: 02/24/2011
08/04/2011 FULL 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " CLASS B DEFICIENCY   APPEALED: 09/02/2011
08/04/2011 FULL 132.60(1)(b) , "RESIDENT CARE/DECUBITI PREVENTION " CLASS B DEFICIENCY   APPEALED: 09/02/2011

*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=GOLDEN AGE MANOR, AMERY, 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++
01/26/2011 COMPLAINT 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 02/26/2011 NO APPEAL ON RECORD
08/18/2011 FULL/COMPLAINT 132.60(8)(b) , "UPDATING OF CARE PLANS " CLASS B DEFICIENCY   NO APPEAL ON RECORD
08/18/2011 FULL/COMPLAINT 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " 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=GOLDEN LIVINGCENTER-BRADLEY, 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++
07/11/2011 FULL/COMPLAINT 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " CLASS B DEFICIENCY UNCORRECTED AT REVISIT NO APPEAL ON RECORD
07/11/2011 FULL/COMPLAINT 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 08/18/2011 NO APPEAL ON RECORD
08/18/2011 COMPLAINT HFS 12.08 , "ARMED FORCES BACKGROUND SEARCHES " CLASS C DEFICIENCY -- CORRECTION ORDER SERVED   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=GOLDEN LIVINGCENTER-COLONIAL MNR, GLENDALE, 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++
01/12/2011 FULL/COMPLAINT 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " CLASS B DEFICIENCY CORRECTED 02/15/2011 APPEALED: 02/10/2011
01/12/2011 FULL/COMPLAINT 132.60(5)(a)1 , "RESIDENT CARE/ORDERS " CLASS B DEFICIENCY CORRECTED 02/15/2011 APPEALED: 02/10/2011
01/12/2011 FULL/COMPLAINT 132.60(5)(d)2 , "RESIDENT CARE/ADM OF MEDS " CLASS B DEFICIENCY CORRECTED 02/15/2011 APPEALED: 02/10/2011
05/05/2011 COMPLAINT 132.60(5)(a)1 , "RESIDENT CARE/ORDERS " CLASS C DEFICIENCY CORRECTED 06/05/2011 NO APPEAL ON RECORD
05/05/2011 COMPLAINT 132.60(5)(d)2 , "RESIDENT CARE/ADM OF MEDS " CLASS C DEFICIENCY CORRECTED 06/05/2011 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=GOLDEN LIVINGCENTER-COURT MANOR, ASHLAND, 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++
08/25/2011 COMPLAINT 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " 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=GOLDEN LIVINGCENTER-DORCHESTER, STURGEON BAY, 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++
08/23/2011 FULL/COMPLAINT 132.62(3) , "NURSING ASSIGNMENTS " CLASS B DEFICIENCY CORRECTED 09/22/2011 NO APPEAL ON RECORD
08/23/2011 FULL/COMPLAINT 50.09(1)(L) , "Care " CLASS B DEFICIENCY CORRECTED 09/22/2011 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=GOLDEN LIVINGCENTER-GOLDEN AGE, TOMAHAWK, 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++
03/29/2011 FULL/COMPLAINT 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " CLASS B DEFICIENCY CORRECTED 05/12/2011 APPEALED: 04/18/2011

*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=GOLDEN LIVINGCENTER-RIB LAKE, RIB LAKE, 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++
11/09/2010 COMPLAINT 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " CLASS B DEFICIENCY CORRECTED 11/18/2010 APPEALED: 11/22/2010

*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=GOLDEN LIVINGCENTER-RIVERVIEW, TOMAHAWK, 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++
10/14/2010 FULL 132.60(1)(c)2 , "RESIDENT CARE/BASIC NRSG CARE " CLASS B DEFICIENCY CORRECTED 11/06/2010 NO APPEAL ON RECORD
10/14/2010 FULL 50.04(2)(d) , "REQUIRED PERSONNEL Daily Minimum Staffing " CLASS C DEFICIENCY -- CORRECTION ORDER SERVED CORRECTED 11/06/2010 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=GOLDEN LIVINGCENTER-SHEBOYGAN, SHEBOYGAN, 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++
05/24/2011 FULL 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 06/24/2011 APPEALED: 06/17/2011

*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=GOLDEN LIVINGCENTER-SILVER SPRING, GLENDALE, 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++
11/04/2010 COMPLAINT 132.60(1)(c)4 , "RESIDENT CARE/BASIC NRSG CARE " CLASS B DEFICIENCY CORRECTED 08/06/2010 NO APPEAL ON RECORD
02/08/2011 FULL/COMPLAINT 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " CLASS B DEFICIENCY CORRECTED 03/14/2011 SETTLED
06/02/2011 COMPLAINT 50.065(3)(b) , "COMPLETE BACKGROUND CHECK PROCESS " CLASS C DEFICIENCY -- CORRECTION ORDER SERVED CORRECTED 07/01/2011 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=GOLDEN LIVINGCENTER-SUPERIOR, SUPERIOR, 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++
03/28/2011 COMPLAINT 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 01/21/2011 NO APPEAL ON RECORD
07/13/2011 FULL 132.60(8)(b) , "UPDATING OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 08/12/2011 APPEALED: 08/05/2011

*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=GOLDEN LIVINGCENTER-THREE OAKS, MARSHFIELD, 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++
11/11/2010 FULL/COMPLAINT 132.51(2)(c) , "ADMISSIONS/DESTRUCTIVE RESIDENTS " CLASS B DEFICIENCY CORRECTED 12/15/2010 DISMISSED
02/24/2011 COMPLAINT 132.51(2)(c) , "ADMISSIONS/DESTRUCTIVE RESIDENTS " CLASS B DEFICIENCY CORRECTED 03/18/2011 APPEALED: 03/14/2011

*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=GOLDEN LIVINGCENTER-VALLEY OF HAYWARD, HAYWARD, 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++
10/14/2010 FULL 50.04(2)(d) , "REQUIRED PERSONNEL Daily Minimum Staffing " CLASS C DEFICIENCY -- CORRECTION ORDER SERVED CORRECTED 11/23/2010 NO APPEAL ON RECORD
06/29/2011 COMPLAINT 50.09(1)(k) , "Abuse and Restraints " CLASS B DEFICIENCY CORRECTED 07/29/2011 APPEALED: 07/18/2011

*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=GOLDEN LIVINGCENTER-VILLAGE GARDENS, GREEN BAY, 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++
03/10/2011 COMPLAINT 132.60(8)(b) , "UPDATING OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 04/10/2011 APPEALED: 04/06/2011
03/10/2011 COMPLAINT 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 04/10/2011 APPEALED: 04/06/2011
08/04/2011 COMPLAINT 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 08/28/2011 APPEALED: 08/25/2011
08/04/2011 COMPLAINT 132.62(3) , "NURSING ASSIGNMENTS " CLASS B DEFICIENCY CORRECTED 08/28/2011 APPEALED: 08/25/2011

*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=GOLDEN LIVINGCENTER-WATERTOWN, WATERTOWN, 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++
07/20/2011 COMPLAINT 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 07/21/2011 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=GOLDEN LIVINGCENTER-WISCONSIN DELLS, WISCONSIN DELLS, 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++
02/09/2011 COMPLAINT 132.53(4)(b) , "TRANSFER AGREEMENTS " CLASS C DEFICIENCY -- CORRECTION ORDER SERVED CORRECTED 03/07/2011 NO APPEAL ON RECORD
05/10/2011 COMPLAINT 50.09(1)(k) , "Abuse and Restraints " CLASS A DEFICIENCY CORRECTED 06/09/2011 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=GOLDEN YEARS HLTH CTR, WALWORTH, 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++
06/20/2011 FULL 132.51(2)(b) , "ADMISSIONS/COMMUNICABLE DISEASE " CLASS B DEFICIENCY CORRECTED 07/20/2011 APPEALED: 07/11/2011
06/20/2011 FULL 132.60(1)(b) , "RESIDENT CARE/DECUBITI PREVENTION " CLASS B DEFICIENCY CORRECTED 08/26/2011 APPEALED: 07/11/2011

*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=GOOD SAMARITAN SOCIETY-LODI, LODI, 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++
05/17/2011 FULL 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " CLASS B DEFICIENCY CORRECTED 06/17/2011 NO APPEAL ON RECORD
05/17/2011 FULL 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " 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=GOOD SAMARITAN SOCIETY-SCANDIA VILLAGE, SISTER BAY, 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++
03/03/2011 FULL/COMPLAINT HFS 12.08 , "ARMED FORCES BACKGROUND SEARCHES " CLASS C DEFICIENCY -- CORRECTION ORDER SERVED CORRECTED 04/03/2011 NO APPEAL ON RECORD
03/03/2011 FULL/COMPLAINT 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " CLASS B DEFICIENCY CORRECTED 04/01/2011 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=GOOD SAMARITAN SOCIETY-ST CROIX VALLEY, ST CROIX FALLS, 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++
08/25/2011 FULL/COMPLAINT 50.065(2)(b)intro , "ENTITY BACKGROUND CHECK REQUIREMENTS " CLASS C DEFICIENCY -- CORRECTION ORDER SERVED   NO APPEAL ON RECORD
08/25/2011 FULL/COMPLAINT 50.065(6)(am) , "Four Year Caregiver Background Requirement " CLASS C DEFICIENCY -- CORRECTION ORDER SERVED   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=GOOD SHEPHERD SERVICES LTD, SEYMOUR, 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++
03/11/2011 FULL 132.72(3) , "POISONS " CLASS B DEFICIENCY CORRECTED 04/11/2011 NO APPEAL ON RECORD
03/11/2011 FULL 50.09(1)(L) , "Care " CLASS B DEFICIENCY CORRECTED 04/11/2011 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=GRACE HEALTHCARE OF RIVER FALLS, RIVER FALLS, 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++
01/11/2011 COMPLAINT 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 02/11/2011 APPEALED: 01/31/2011
03/10/2011 FULL 50.09(1)(L) , "Care " CLASS B DEFICIENCY CORRECTED 04/25/2011 APPEALED: 04/04/2011

*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=GRANCARE NURSING AND REHAB CTR, 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++
12/13/2010 FULL 132.60(1) , "RESIDENT CARE/INDIVIDUAL CARE " CLASS B DEFICIENCY CORRECTED 01/17/2011 APPEALED: 12/29/2010
12/13/2010 FULL 132.60(1)(b) , "RESIDENT CARE/DECUBITI PREVENTION " CLASS B DEFICIENCY   APPEALED: 12/29/2010
12/13/2010 FULL 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY UNCORRECTED AT REVISIT APPEALED: 12/27/2010
12/13/2010 FULL 132.62(2)(b)1.a , "CHARGE NURSE/LESS THAN 60 RES. " CLASS C DEFICIENCY -- CORRECTION ORDER SERVED CORRECTED 01/17/2011 APPEALED: 12/27/2010
12/13/2010 FULL 132.60(1)(c)5 , "FACILITY SHALL PROVIDE PAIN ASSESSMNT/TREATMT" CLASS B DEFICIENCY CORRECTED 01/17/2011 APPEALED: 12/27/2010
01/27/2011 REVISIT 132.60(8)(c) , "IMPLEMENTATION OF CARE PLANS " CLASS B DEFICIENCY CORRECTED 02/28/2011 APPEALED: 02/14/2011
01/27/2011 REVISIT 50.09(1)(L) , "Care " CLASS B DEFICIENCY CORRECTED 02/28/2011 APPEALED: 02/14/2011

*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=GRAND VIEW CARE CTR, BLAIR, 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++
03/21/2011 FULL/COMPLAINT 132.31(1)(d)2 , "ADMISSION INFORMATION " CLASS C DEFICIENCY -- CORRECTION ORDER SERVED 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=GRANDE PRAIRIE HLTH REHAB CTR, PLEASANT PRAIRIE, 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++
11/23/2010 FULL/COMPLAINT 132.60(1)(b) , "RESIDENT CARE/DECUBITI PREVENTION " CLASS B DEFICIENCY UNCORRECTED AT REVISIT DISMISSED
01/07/2011 REVISIT 132.60(1)(b) , "RESIDENT CARE/DECUBITI PREVENTION " CLASS B DEFICIENCY CORRECTED 02/17/2011 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.