Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nu Roc Health And Rehabilitation Ctr during CMS and state inspections, most recent first.
The facility failed to ensure staff were aware of and implemented Enhanced Barrier Precautions (EBP) for three residents with indwelling urinary catheters and/or a history of MRSA. One resident with chronic kidney disease and a catheter had no EBP order or special instructions in the clinical orders, no EBP signage in the room, and an RN who entered to provide care was unaware of any need for PPE. Two additional residents with catheters had clinical orders specifying EBP, but there was no EBP signage in their rooms. CNAs reported relying on assignment sheets or verbal communication to identify EBP residents, yet the assignment sheet did not list EBP status, and one CNA stated she was not notified of any residents on EBP. An LPN indicated that EBP information was on Kardexes in binders on residents’ doors, but review of these Kardexes showed no EBP notation for the affected residents, and the DON acknowledged that residents who should be on EBP did not have appropriate signage or postings.
Surveyors found that staff did not monitor or document food cooling temperatures, failed to test and log sanitizing solution concentrations, and did not ensure warewashing machines reached required temperatures. Numerous food items were undated, expired, or improperly labeled, and staff confirmed these practices did not follow facility policy or FDA Food Code.
A resident with a diagnosis of major depressive disorder and prescribed mirtazapine was admitted without an accurate PASRR Level I Screen, which failed to note the mental health diagnosis and medication. This omission resulted in the required PASRR Level II evaluation not being completed to determine the need for specialized services.
Surveyors found that two residents were exposed to accident hazards due to staff not following care plans and safety protocols. One resident's oxygen concentrator was left running in the room while not in use, contrary to policy, and another resident with cognitive and mobility impairments was encouraged by the Maintenance Director to self-transfer without required staff assistance.
Two residents did not receive medications as ordered: one was given a chewable aspirin instead of the prescribed enteric coated form, and another had a lidocaine patch applied to the knee instead of the back and at the wrong time. These errors were observed during medication administration by an LPN and confirmed by the DON.
A resident with a PEG tube, who was on Enhanced Barrier Precautions, received medication from an LPN who failed to wear a gown as required by facility policy. Both the LPN and DON confirmed that a gown should have been used during this high-contact care activity.
The facility did not submit accurate direct care staffing information to CMS, as required by federal regulations. Although internal records showed sufficient staffing levels, the PBJ report triggered for low weekend staffing due to a suspected reporting or timecard system error, particularly with agency staff hours. This discrepancy affected all residents in the facility.
The facility failed to submit accurate PBJ data for Q4 2023 and Q1 2024 due to complications from switching payroll software. The new system incorrectly divided hours for agency staff, leading to inaccurate staffing data. The issue was identified and corrected by January 31, 2024, but the deficiency was cited as past noncompliance.
The facility failed to sanitize mechanical lifts used for transferring residents, as observed in two separate instances. In one case, a resident with multiple fractures was transferred using a lift that was not sanitized afterward. In another case, a CNA admitted that staff do not sanitize lifts or have a cleaning schedule for them, even during a COVID outbreak. This indicates non-compliance with the facility's infection prevention and control policy.
A resident with a history of multiple traumas was admitted to the facility and experienced re-traumatization due to inadequate trauma-informed care. The resident's care plan did not include identified triggers, and an incident involving smoking in the room led to distressing 1:1 monitoring conditions. The resident felt re-traumatized by the search of her room and the monitoring, which worsened her depression.
Failure to Communicate and Implement Enhanced Barrier Precautions for Residents with Indwelling Catheters
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff were aware of and implemented Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters and/or MDRO history, as required by the facility’s own policy. The EBP policy stated that an order for EBP would be obtained for residents with wounds or indwelling medical devices and that the facility would ensure staff were aware of which residents required EBP prior to providing high-contact care. However, for one resident with an indwelling catheter, there was no physician order for EBP or special instructions in the clinical physician orders, and no signage in the room to indicate EBP status. Surveyors identified three residents with indwelling urinary catheters who should have been on EBP but lacked appropriate communication measures. One resident with chronic kidney disease and an indwelling catheter had catheter tubing visible at the base of the pant leg, yet there was no EBP signage in the room, and a registered nurse who entered to connect portable oxygen stated he was not aware the resident was on EBP and did not know if PPE should have been used. Another resident with neuromuscular bladder dysfunction and an indwelling catheter had clinical orders noting a history of MRSA and EBP, but there was no signage in the room to indicate EBP. A third resident with urinary retention and an indwelling catheter also had special instructions for EBP in the clinical orders, but no EBP signage was observed in the room. Staff interviews and document reviews showed that frontline staff did not have a reliable method to identify which residents were on EBP. A CNA stated that EBP information was on the assignment sheet, but the posted assignment sheet only listed staff and their assigned areas and did not indicate EBP status. Another CNA reported that EBP information was communicated “pretty much vocal” and that she was not notified of any residents on EBP when receiving her assignment. An LPN stated that EBP information was on the Kardex in yellow binders on the back of residents’ doors, but review of the Kardexes for the three residents showed no mention of EBP despite their indwelling catheters. The DON acknowledged that residents who should be on EBP did not have signage or postings and that she was aware of what staff had reported about the location and communication of EBP information.
Failure to Maintain Safe and Sanitary Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a safe and sanitary manner, as evidenced by multiple observations and staff interviews. Staff did not monitor or document food cooling temperatures, and there was no food cooling log present in the kitchen. Cooked foods such as egg salad and pasta salad were found in the walk-in cooler without proper documentation of cooling procedures, and the Dietary Manager confirmed that there was no established process for cooling and storing leftover foods for later consumption. Staff routinely saved cooked food that was not cooled properly, leading to frequent disposal of these items. Sanitizing procedures were also not followed according to manufacturer instructions. Staff used quaternary sanitizing solution to clean food preparation surfaces but did not test the solution for proper parts per million (PPM) concentration or temperature, nor did they maintain a log for this purpose. Dietary staff confirmed that they did not test or document the PPM of the sanitizing solution, and there was no established procedure for monitoring this critical aspect of food safety. The warewashing process was not adequately monitored or documented. The dishwashing machine did not consistently reach the manufacturer's recommended wash and rinse temperatures, and logs showed multiple entries where temperatures and PPM were out of range. Staff did not rerun dishes through the machine when minimum temperatures were not met, and the machine's thermometer was found to be malfunctioning. Additionally, numerous food items in the walk-in cooler, freezer, and dry storage were found to be undated, expired, or improperly labeled, including bread, buns, cheese, pancakes, meat products, and canned goods. The Dietary Manager confirmed these items were not compliant with facility policy or FDA Food Code requirements.
Failure to Complete Accurate PASRR Screening for Mental Health Disorder
Penalty
Summary
The facility failed to ensure that a Pre-admission Screening and Resident Review (PASRR) Level II Screen was completed for one resident who had a diagnosis of major depressive disorder and was prescribed mirtazapine, an antidepressant. The resident's PASRR Level I Screen, which was completed after admission, inaccurately indicated that the resident did not have a major mental health disorder and was not prescribed psychotropic medication for such a disorder. As a result, a PASRR Level II Screen was not submitted to determine the need for specialized services. Record review and staff interview confirmed that the resident was admitted with a diagnosis of major depressive disorder and was receiving antidepressant medication. The facility's policy requires accurate completion of the PASRR Level I Screen prior to admission, and a positive screen should trigger a Level II evaluation by the state-designated authority. However, the Level I Screen omitted the resident's mental health diagnosis and medication, leading to the failure to initiate the required Level II evaluation.
Failure to Prevent Accident Hazards and Ensure Safe Supervision
Penalty
Summary
Surveyors identified deficiencies related to accident hazards and inadequate supervision for two residents. One resident with chronic obstructive pulmonary disease (COPD) and heart failure had a physician's order for continuous oxygen via nasal cannula. On observation, the resident's oxygen concentrator was left running at 4 liters per minute in the room while the resident was not present, and the nasal cannula was left on the bed. The resident confirmed not using portable oxygen during certain activities, and both a CNA and the Director of Nursing verified that the concentrator should have been turned off when not in use, as per facility policy and safe oxygen use guidelines. Another resident with dementia, mobility issues, and a history of falls was observed being encouraged by the Maintenance Director to transfer independently from a wheelchair to bed, despite the care plan specifying the need for one-person assistance during transfers. The Maintenance Director did not check the care plan before encouraging the resident to self-transfer and later acknowledged this oversight. A CNA confirmed the resident should have assistance, and the Director of Nursing stated that the Maintenance Director should not have facilitated or encouraged the transfer.
Medication Administration Errors Involving Two Residents
Penalty
Summary
Two residents were not provided with safe administration of medications as required by facility policy. One resident, who had diagnoses including diabetes, COPD, and epilepsy and a BIMS score indicating moderately impaired cognition, had a physician's order for 81 mg enteric coated (EC) aspirin daily for DVT prophylaxis. Instead, the resident was administered an 81 mg chewable aspirin tablet, which did not match the prescribed form. The error was identified when the medication order was reviewed and it was found that the order had been transcribed incorrectly due to the facility not carrying the capsule form, and the original order specified EC aspirin. Another resident, with a history of acute gastrojejunal ulcer with perforation, pain, and a gastrostomy and a BIMS score indicating intact cognition, had a physician's order for a 4% lidocaine patch to be applied to the back at bedtime and removed in the morning. During a medication pass, an LPN applied the patch to the resident's left knee instead of the back and at the wrong time of day. The DON confirmed that the patch should have been applied to the back at bedtime and removed in the morning, as per the order.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow the facility's Enhanced Barrier Precautions (EBP) policy while providing care to a resident with a percutaneous endoscopic gastrostomy (PEG) tube. The resident, who had a history of acute gastrojejunal ulcer with perforation and a gastrostomy, was on EBP due to the presence of an indwelling medical device. During medication administration via the PEG tube, the LPN performed hand hygiene and donned gloves but did not wear a gown as required by the facility's EBP policy. Both the LPN and the Director of Nursing (DON) acknowledged that a gown should have been worn during this high-contact care activity.
Inaccurate Submission of Staffing Data to CMS
Penalty
Summary
The facility failed to ensure that complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, was submitted to the Centers for Medicare & Medicaid Services (CMS) as required. During a review of the Payroll Based Journal (PBJ) Staffing Data Report for the second fiscal quarter, the surveyor noted that the facility triggered for excessively low weekend staffing. However, upon review of timecard punches and staffing totals for the same period, it was found that there were no low weekend hours and the facility consistently maintained nursing hours above the required minimum. The facility assessment also confirmed that staffing was appropriate for the resident population. Interviews with the Business Office Manager (BOM) and Director of Operations (DOO) revealed that the facility reviews staffing hours daily to ensure accurate reporting, but the employee responsible for submitting the PBJ data was on medical leave and unavailable for clarification. Both the BOM and DOO were unable to explain why the PBJ report indicated low weekend staffing, suspecting a possible error in the reporting or timecard system, particularly regarding agency staffing hours. This discrepancy resulted in the submission of inaccurate staffing data to CMS, potentially affecting all 34 residents in the facility.
Inaccurate PBJ Data Submission Due to Payroll Software Switch
Penalty
Summary
The facility failed to submit accurate data to the Centers for Medicare and Medicaid Services (CMS) mandatory Payroll Based Journal (PBJ) for the fourth quarter of 2023 and the first quarter of 2024. This issue was identified when the facility triggered for excessively low weekend staffing during these periods. Upon review, the surveyor found no evidence of excessively low weekend staffing in the daily postings, nursing schedules, and timecard punches for the specified quarters. The Nursing Home Administrator (NHA) confirmed that staffing needs were based on census and that they used agency staff daily, denying any excessively low weekend staffing. Further investigation revealed that the facility switched payroll software on October 1, 2023, which led to complications in accurately recording staffing data. The Business Office Manager (BOM) explained that the new system required manual entry of schedules, and any changes due to agency staff calling out or picking up extra hours resulted in the program incorrectly dividing the hours. This issue was recognized in January, and since then, the facility has been manually checking and entering hours to ensure accuracy. The facility was in compliance as of January 31, 2024, but the deficiency was cited as past noncompliance.
Failure to Sanitize Mechanical Lifts
Penalty
Summary
The facility did not ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to sanitize mechanical lifts used for transferring residents. In one instance, a resident with reduced mobility and multiple fractures was transferred using a mechanical lift by two CNAs. After the transfer, the mechanical lift was pushed directly into the storage area without being sanitized. The Director of Nursing confirmed that CNAs are expected to wipe down lifts between residents, which was not done in this case. In another instance, a different resident was assisted with a sit-to-stand transfer using a mechanical lift. After the transfer, the CNA did not sanitize the lift before placing it in the storage room. Upon questioning, the CNA admitted that staff do not sanitize lifts or have a cleaning schedule for them, and she was unsure if housekeeping did. The CNA also stated that she had never been instructed to sanitize lifts, even during a COVID outbreak, and had not been doing so. This indicates a lack of adherence to the facility's infection prevention and control policy, which requires special cleaning, disinfection, or sterilization of reusable items and equipment.
Failure to Create Trauma-Informed Care Plan
Penalty
Summary
The facility did not ensure the creation of a culturally competent, trauma-informed care plan for a resident with an identified trauma history. The resident, who had a history of multiple traumas including physical and sexual assault, was admitted to the facility after hospitalization for a COVID infection and was homeless due to a recent eviction. Despite the resident's disclosure of past traumas and the facility's policy to address trauma-informed care, the care plan did not include identified triggers or specific interventions to mitigate re-traumatization. An incident occurred where the resident was found smoking in her room, leading to a confrontation with staff and law enforcement. The resident was placed on 1:1 monitoring, which involved keeping the room light on and the door cracked open, conditions that the resident found distressing and exacerbated her PTSD. The resident expressed that the 1:1 monitoring and the search of her room by staff and law enforcement made her feel re-traumatized, likening the experience to her childhood trauma. The resident's care plan was not updated to include specific triggers until several months after the incident, despite the resident's willingness to share her triggers if asked. The facility's failure to identify and address the resident's triggers in a timely manner contributed to the resident's distress and feelings of re-traumatization. The resident reported that the incident worsened her depression and that her trauma was not adequately addressed by the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Laona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Freeman Nursing & Rehabilitation Community | 31.5 mi | — | 5 | 0 |
| Optalis Health And Rehabilitation Of Kingsford | 32.2 mi | — | 2 | 0 |
| Florence Health Services | 33.3 mi | — | 7 | 0 |
| Maryhill Manor | 34.2 mi | — | 7 | 0 |
| Newcare | 35 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.