Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Stevens Point Health Services
Stevens Point, WI · 50 certified beds · Last Life Safety survey July 23, 2025
CMS Certification Number 525353 · first certified March 1984
Ownership
Operated by NORTH SHORE HEALTHCARE · For profit - Limited Liability company
- Ownership changed December 1, 2019 (change of ownership)from STEVENS POINT CARE CENTER LLC
Position within WI
20 citations — more than 58% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 4.7. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: September 2026 to October 2026. This facility’s last Life Safety survey was July 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
4 of the 20 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
9 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 20 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 20 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 18, 2023 | 3 |
| November 22, 2023 | 1 |
| May 8, 2024 | 10 |
| July 23, 2025 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2025-07-23 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 3 | 2025-07-23 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-07-23 |
| E-0020 | Establish policies and procedures including evacuation. | 1 | 2025-07-23 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2023-04-18 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2024-05-08 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-05-08 |
| E-0035 | Provide family notifications of emergency plan. | 1 | 2024-05-08 |
What the citations cover
- Smoke Deficiencies 7
- Emergency Preparedness Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Services Deficiencies 4
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Emergency Preparedness Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Services Deficiencies | 4 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 23, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (August 18, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 18, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (July 23, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 18, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has no plan of correction |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (August 12, 2025) |
May 8, 2024 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (June 21, 2024) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (August 1, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (June 21, 2024) |
November 22, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 15, 2023) |
April 18, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (May 11, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (May 11, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 11, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.