Deficiency Index

Hope Health and Rehab

Lomira, Wisconsin · CCN 525642

20 surveys since 2010. The first finding at harm level was recorded in 2025.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
80
Surveys
20
Harm or worse
1
Immediate jeopardyall corrected before survey
1
The record, 2010–2026
’10’15’20’25’26
No harm recordedHarm or worseNot surveyed
Immediate jeopardy1

Findings at the most serious level CMS records. All were recorded as past non-compliance — corrected before the survey.

Beyond CMS’s monthly file15/20

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
38
Ownership
For profit - Corporation
Chain
Independent
County
Dodge · rural
Medicare-certified since
1998

CMS ratings

Overall
5
Health inspection
4
Staffing
5
Quality measures
3

CMS’s own Five-Star ratings.

Compared with similar facilities

Since 2021, this facility recorded somewhat more weighted findings than its peer group.

Weighted by harm level, against 92 for-profit facilities with fewer than 66 beds in Wisconsin.

Last survey on record

Jun 18, 2026

144 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day4.953.73
Registered-nurse hours per resident day1.60—
Annual nurse turnover22.7%45.7%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

No fines, payment denials or special-focus designation on the current CMS record.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ14.8%K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD1361.9%E419.0%F314.3%
No harm, potential for minimalA—B—C—
CMS’s current file: 21 of the 80 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F8123×

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • F6842×

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • F5801×

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • F5841×

    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.

  • F6091×

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

In the surveyor’s words

From the most serious findings on record at Hope Health and Rehab, in the surveyor’s own words.

  • Immediate jeopardy, isolatedF684May 1, 2025

    Based on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 3 residents identified in closed records review (R31). R31 presented with a change in condition (COC) on [DATE]. Facility staff did not document all R31's symptoms in R31's medical record and did not complete a thorough and ongoing RN (Registered Nurse) assessment related to the COC. R31's condition continued to decline. R31's vital signs warranted immediate MD (Medical Doctor) notification/consultation and the facility did not notify the MD. […]

  • No harm, potential for more than minimal, widespreadF812Jun 18, 2026

    Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 32 residents who reside in the facility. Surveyor observed [NAME] E use the same dirty alcohol wipe to sanitize a thermometer while testing the temperature of several foods. Surveyor observed DA D (Dietary Aide) washing dirty dishes causing his clothing to get wet and then Surveyor observed DA D carrying clean dishes up against his dirty/wet clothing to put them away. Surveyor also observed DA D to not wash his hands after cleaning dirty dishes and before putting away clean dishes. Surveyor observed food in the resident refrigerator to be undated and unlabeled. […]

  • No harm, potential for more than minimal, widespreadF812May 1, 2025

    Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 26 of 27 residents. Surveyor observed dust in the facility's stove hood, over open food being prepared for resident meals. Surveyor observed food to have been removed from the original packaging and not sealed or dated with an expiration date, an open date, or a use by date. Surveyor observed a box of potatoes on the floor in the dry food storage area. Evidenced by: Example 1 Facility's Cooks Weekly Cleaning Tasks sheet, undated, states in part: Sunday, Hood cleaning above stove, AM cook, take vent down run thru dishwasher. […]

  • No harm, potential for more than minimal, widespreadF812Mar 19, 2024

    Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 34 residents. Surveyor observed Mighty Shakes to be in the refrigerator for more than the manufacturer's recommendations of 14 days. Surveyor observed hairlike dust moving in the air exchange, in the facility's stove hood, over open food being prepared for resident meals. Surveyor observed a dented can in circulation. Surveyor observed food to have been removed from the original packaging and not dated with an expiration date, an open date, or a use by date. […]

  • No harm, potential for more than minimal, widespreadF812Jan 12, 2022

    Based on observation, interview, and record review the facility did not ensure food was stored and prepared in a safe and sanitary manner, which had the potential to affect all 26 Residents (R) at the facility. ~Staff were not using the proper dishwasher test strips and falsely documented test strip readings within normal limits. ~Milk temperatures during breakfast service exceeded allowable cold hold temperatures ~Items in the cooler were not stored or dated properly or were expired ~The microwave was not clean ~Packaged Food items were located under a rack in the dry storage area. […]

Read 20 findings in full →The most serious and the most recent: 20 of 80 on record.

Every survey on record

FindingsAt actual harm or above

  • Jun 18, 2026Standard and complaint2 findings
  • Dec 2, 2025Complaint1 finding
  • May 1, 2025Standard9 findings · 1 harm
  • Mar 19, 2024Standard2 findings
  • Mar 22, 2023Complaint3 findings
  • Jan 12, 2023Standard7 findings
  • Sep 18, 2022Complaint2 findings
  • Jan 12, 2022Standard2 findings
Show the 12 earlier surveys
  • Nov 30, 2020Infection control1 finding
  • Feb 19, 2020Standard7 findings
  • Jan 9, 2019Standard1 finding
  • Sep 21, 2017Standard7 findings
  • Aug 1, 2017Complaint1 finding
  • Aug 24, 2016Standard6 findings
  • Aug 4, 2015Complaint1 finding
  • Jun 25, 2015Standard5 findings
  • May 22, 2014Standard2 findings
  • Mar 20, 2013—7 findings
  • Jan 19, 2012—9 findings
  • Dec 22, 2010—5 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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