01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-07-17 | 6 | 2025-07-17 | 5 |
| Cycle 2 | 2024-05-15 | 9 | 2024-05-15 | 7 |
| Cycle 3 | 2023-05-10 | 3 | 2023-05-10 | 2 |
CMS CCN 5254972026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
The Pines Post Acute And Memory Care
1625 E Main St · Clintonville, WI 54929 · Waupaca County
Certified beds50CMS provider file
Recent citation rows32current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
32 rows in the current release
2 rows carry G–L scope/severity codes; 1 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-07-17 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2025-08-082025-07-17 · HEALTHF0628Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2025-08-082025-07-17 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-08-082025-07-17 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2025-08-082025-07-17 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-08-082025-07-17 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-08-082025-07-17 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-08-212025-07-17 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-08-082025-07-17 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-08-082025-07-17 · FIREK0355Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2025-08-082025-07-17 · FIREK0511Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-08-082025-06-19 · HEALTHF0607Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2025-07-04 · complaint2025-06-19 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-07-04 · complaint2025-05-01 · HEALTHF0604Severity J · isolated immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Correction field: Past Non-Compliance · 2025-04-02 · complaint2025-05-01 · HEALTHF0607Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2025-05-28 · complaint2024-05-15 · FIREE0025Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Create arrangements with other facilities to receive patients.
Correction field: Deficient, Provider has date of correction · 2024-06-072024-05-15 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2024-06-102024-05-15 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-06-102024-05-15 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-06-102024-05-15 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-06-102024-05-15 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-06-102024-05-15 · FIREK0211Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2024-06-102024-05-15 · FIREK0311Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Have an enclosure around a vertical opening shaft.
Correction field: Deficient, Provider has date of correction · 2024-06-072024-05-15 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2024-06-0703 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-06-19 | Fine | $11,960 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- GATEWAY HEALTHCARE LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/01/2014
- THE ENSIGN GROUP INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 05/23/2011
- BELL, CODYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/01/2014
- KAMIN, SHAYNAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2024
- BURNAM, SOONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/20/2013
- JORGENSEN, DAVIDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/09/2024
- KEETCH, CHADIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2011
- J THOMPSON STAFFING INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2014
- KELSTAR LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2014
- PRN HEALTH SERVICES, INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2014
- BELL, CODYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2014
- KAMIN, SHAYNAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2024
- PORT, BARRYIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 10/15/2025
- ENSIGN SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/20/2013
- LEGEND LAKE HEALTH HOLDINGS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 06/01/2014
- STANDARD BEARER HEALTHCARE OP, LPOrganization · ADP OF THE SNFNOT APPLICABLE · since 06/01/2014
- THE ENSIGN GROUP INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 06/01/2014
- BELL, CODYIndividual · ADP OF THE SNFNOT APPLICABLE · since 06/01/2014
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.40per resident day
RN hours0.46per resident day
Weekend nurse hours3.01per resident day
Staff turnover52.7%CMS reported field
06 / LOCAL RECORDS
Open the Clintonville ledger →