Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
NORTHERN LIGHTS HCC
WASHBURN, WI · 50 certified beds · Last Life Safety survey July 30, 2025
CMS Certification Number 525567 · first certified April 1995
Ownership
Operated by HEALTH DIMENSIONS GROUP · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WI
23 citations — more than 67% 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 11 citations; the earlier surveys in the window averaged 6. With 3 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 November 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
3 of the 23 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)
7 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 23 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 | 23 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 10, 2023 | 6 |
| May 22, 2024 | 6 |
| July 30, 2025 | 11 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 2 | 2024-05-22 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2025-07-30 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-07-30 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-07-30 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2024-05-22 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2025-07-30 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-05-22 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2024-05-22 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Miscellaneous Deficiencies 5
- Smoke Deficiencies 5
- Egress Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Miscellaneous Deficiencies | 5 |
| Smoke Deficiencies | 5 |
| Egress Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 3 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 30, 2025 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (September 11, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (September 11, 2025) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (September 11, 2025) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (September 11, 2025) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (September 11, 2025) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (September 11, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (September 11, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 11, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 11, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (September 11, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 11, 2025) |
May 22, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 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-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 21, 2024) |
May 10, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (June 19, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 19, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 19, 2023) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (June 19, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (June 19, 2023) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (June 19, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.