01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-06-17 | 5 | 2026-06-17 | 2 |
| Cycle 2 | 2025-03-19 | 7 | 2025-03-19 | 13 |
| Cycle 3 | 2024-01-31 | 5 | 2024-01-31 | 10 |
CMS CCN 5257182026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Wi Veterans Home Moses Hall
210 Cumberlidge Ave · King, WI 54946 · Waupaca County
Certified beds192CMS provider file
Recent citation rows42current 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
42 rows in the current release
4 rows carry G–L scope/severity codes; 1 carry J–L. 7 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-17 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-07-172026-06-17 · 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: Past Non-Compliance · 2026-05-15 · complaint2026-06-17 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2026-07-172026-06-17 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2026-07-172026-04-20 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2026-05-14 · complaint2026-04-20 · HEALTHF0684Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Past Non-Compliance · 2026-02-05 · complaint2026-04-20 · 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 · 2026-05-14 · complaint2025-03-19 · FIREE0013Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop Emergency Preparedness policies and procedures.
Correction field: Deficient, Provider has date of correction · 2025-04-182025-03-19 · FIREE0022Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures for sheltering.
Correction field: Deficient, Provider has date of correction · 2025-04-182025-03-19 · FIREE0032Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Provide primary/alternate means for communication.
Correction field: Deficient, Provider has date of correction · 2025-04-182025-03-19 · FIREE0036Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2025-04-182025-03-19 · 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 · 2025-04-152025-03-19 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2025-04-15 · complaint2025-03-19 · 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 · 2025-04-152025-03-19 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-04-152025-03-19 · HEALTHF0760Severity G · isolated actual harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-04-152025-03-19 · 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 · 2025-04-182025-03-19 · 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 · 2025-04-152025-03-19 · 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 · 2025-04-032025-03-19 · 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 · 2025-05-302025-03-19 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-04-182025-03-19 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-04-042025-03-19 · FIREK0712Severity C · widespread; potential for minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-05-302025-03-19 · FIREK0741Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2025-04-1803 / 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 |
|---|---|---|---|
| 2026-04-20 | Fine | $23,520 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- STATE OF WISCONSINOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 07/01/2014
- BOND, JAMESIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/09/2023
- PARKER, JAMESIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/22/2012
- SERVATIUS, TAMMYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/14/2025
- STATE OF WISCONSINOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2014
- BOND, JAMESIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/09/2023
- BRITZ, BETTEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/04/2015
- BUTTERFIELD, BRADIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/04/2024
- COONEY, COLTIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/02/2024
- FAY, SUSANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/28/2024
- FERNANDEZ, GINAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/14/2024
- FLACK, NICOLEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/15/2020
- KAZA, THANMAYIIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/31/2023
- KIMBALL, POLLYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/11/2012
- MORK, CAITLINIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/04/2021
- PARKER, JAMESIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/22/2012
- SCHULZ, JODIEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/23/2023
- SERVATIUS, TAMMYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/15/2026
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 hours5.10per resident day
RN hours1.02per resident day
Weekend nurse hours4.59per resident day
Staff turnover32.6%CMS reported field
06 / LOCAL RECORDS
Open the King ledger →