Hopkins Restorative Care Ctr

Inspection findings

1. Mar 12, 2026 Health · 23 findings
   • Not serious Scope/severity D

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected May 15, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected May 15, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected May 15, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0727 Nursing and Physician Services Deficiencies

     Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

     Corrected May 15, 2026 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected May 15, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0847 Administration Deficiencies

     Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

     Corrected May 15, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0848 Administration Deficiencies

     Provide a neutral and fair arbitration process and agree to arbitrator and venue.

     Corrected May 15, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 15, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected May 15, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0887 Infection Control Deficiencies

     Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

     Corrected May 15, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected May 15, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected May 10, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0271 Egress Deficiencies

     Have exits that are accessible at all times.

     Corrected May 10, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected May 10, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected May 10, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 10, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected May 10, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected May 10, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0901 Electrical Deficiencies

     Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

     Corrected May 10, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected May 10, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected May 10, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected May 10, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected May 10, 2026 · CMS fire safety

2. Sep 8, 2025 MDH complaint investigation · 1 finding
   • Severity not stated

     H52932440C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

3. Dec 16, 2024 Fire Safety · 35 findings
   • Not serious Scope/severity F

     E0037 Emergency Preparedness Deficiencies

     Establish staff and initial training requirements.

     Corrected Jan 31, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Jan 31, 2025 · CMS fire safety

   • Not serious Scope/severity C

     F0574 Resident Rights Deficiencies

     The resident has the right to receive notices in a format and a language he or she understands.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity C

     F0577 Resident Rights Deficiencies

     Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

     Corrected Jan 21, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0578 Resident Rights Deficiencies

     Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0580 Resident Rights Deficiencies

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

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0582 Resident Rights Deficiencies

     Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0584 Resident Rights Deficiencies

     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.

     Corrected Feb 15, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0676 Quality of Life and Care Deficiencies

     Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Jan 16, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0690 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.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0725 Nursing and Physician Services Deficiencies

     Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0730 Nursing and Physician Services Deficiencies

     Observe each nurse aide's job performance and give regular training.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Jan 7, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0908 Environmental Deficiencies

     Keep all essential equipment working safely.

     Corrected Jan 13, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Feb 15, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0947 Nursing and Physician Services Deficiencies

     Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Jan 16, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Jan 16, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jan 16, 2025 · CMS fire safety

   • Not serious Scope/severity B

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jan 16, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0346 Smoke Deficiencies

     Follow proper procedures when the fire alarm was out of service for more than 4 hours.

     Corrected Jan 16, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0354 Smoke Deficiencies

     Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

     Corrected Jan 16, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0362 Smoke Deficiencies

     Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

     CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jan 16, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jan 16, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Jan 16, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0901 Electrical Deficiencies

     Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

     Corrected Jan 16, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Jan 16, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jan 16, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0930 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper storage of liquid oxygen.

     Corrected Jan 16, 2025 · CMS fire safety

4. Oct 2, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Oct 24, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Oct 24, 2024 · CMS health inspection

5. Mar 1, 2024 Fire Safety · 23 findings
   • Not serious Scope/severity F

     E0037 Emergency Preparedness Deficiencies

     Establish staff and initial training requirements.

     Corrected Mar 31, 2024 · CMS fire safety

   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Mar 31, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Mar 31, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Mar 31, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0685 Quality of Life and Care Deficiencies

     Assist a resident in gaining access to vision and hearing services.

     Corrected Mar 31, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Mar 31, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Mar 31, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0690 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.

     Corrected Mar 31, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 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.

     Corrected Mar 31, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Mar 31, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0867 Administration Deficiencies

     Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

     Corrected Mar 31, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 31, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Mar 31, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Apr 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0225 Egress Deficiencies

     Have stairways and smokeproof enclosures used as exits that meet safety requirements.

     Corrected Apr 5, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Apr 12, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Apr 1, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Apr 25, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 10, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Mar 14, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Mar 31, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Apr 15, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Mar 31, 2024 · CMS fire safety

6. Sep 26, 2023 MDH complaint investigation · 1 finding
   • Severity not stated

     H52935286C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

7. Sep 13, 2023 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Oct 27, 2023 · CMS health inspection

8. Jun 15, 2022 MDH complaint investigation · 1 finding
   • Severity not stated

     H52932347C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

9. Apr 7, 2022 MDH complaint investigation · 1 finding
   • Severity not stated

     H5293134C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

10. Dec 7, 2021 MDH complaint investigation · 1 finding
    • Severity not stated

      H5293124C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

11. Sep 17, 2021 MDH complaint investigation · 1 finding
    • Severity not stated

      H5293114C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

Owners and managers (as published by CMS)

• BAUMANN, TROY — corporate officer, NOT APPLICABLE, since 04/04/2017
• BAUMANN, TROY — operational/managerial control, NOT APPLICABLE, since 04/04/2017
• HOEHN, JEFFREY — operational/managerial control, NOT APPLICABLE, since 04/04/2017
• HOEHN, JEFFREY — corporate officer, NOT APPLICABLE, since 04/04/2017
• NORTH SHORE HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 04/04/2017
• NSHC WISCONSIN LLC — operational/managerial control, NOT APPLICABLE, since 04/04/2017
• NSHC WISCONSIN LLC — 5% or greater direct ownership interest, 100%, since 04/04/2017