The Pines Post Acute and Memory Care
1625 E Main St, Clintonville, WI 54929 · Waupaca County · 50 certified beds · avg 45 residents/day · certified since Nov 1, 1992
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · May 1, 2025 · F-0604 · triggered by a complaint
The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Why it matters: Unneeded restraints can cause injuries, muscle loss, and deep emotional distress.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 2, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Jun 19, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 4, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (18)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 17, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 17, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 17, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Jul 17, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Jul 17, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 17, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jun 19, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 19, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| May 1, 2025 | ▲ J · Immediate jeopardy, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| May 1, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| May 15, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 15, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 15, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| May 15, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| May 15, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 10, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| May 10, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 10, 2023 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | D |
| 2024 | 5 | 0 | E |
| 2025 | 10 | 2 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $11,960.
| Date | Type | Amount / length |
|---|---|---|
| Jun 19, 2025 | Fine | $11,960 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.27 | 4.29 | 3.95 | bottom 14% in Wisconsin; bottom 25% in the U.S. |
| Registered Nurse hours | 0.44 | 1.01 | 0.69 | bottom 3% in Wisconsin; bottom 29% in the U.S. |
| Weekend total nurse staffing | 2.90 | 3.84 | 3.50 | bottom 14% in Wisconsin; bottom 26% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.33 | 0.68 | 0.48 | bottom 8% in Wisconsin; bottom 39% in the U.S. |
| Total nursing staff turnover (%) | 52.7 | 46.9 | 45.8 | bottom 31% in Wisconsin; bottom 30% in the U.S. |
| RN turnover (%) | 42.9 | 39.7 | 42.9 | bottom 43% in Wisconsin; bottom 49% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.40, RN 0.46, weekend 3.01. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Gateway Healthcare LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 02/01/2014 |
| The Ensign Group INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 05/23/2011 |
| Bell, Cody | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2014 |
| Bell, Cody | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2014 |
| Bell, Cody | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2014 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 12/20/2013 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 12/20/2013 |
| J Thompson Staffing INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/01/2014 |
| Jorgensen, David | Individual | Corporate Officer | NOT APPLICABLE | 09/09/2024 |
| Kamin, Shayna | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2024 |
| Kamin, Shayna | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2024 |
| Kamin, Shayna | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2024 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Kelstar LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/01/2014 |
| Legend Lake Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2014 |
| Port, Barry | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 10/15/2025 |
| PRN Health Services, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/01/2014 |
| Standard Bearer Healthcare Op, LP | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2014 |
| The Ensign Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2014 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your policy on physical restraints, and what alternatives do you try first?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Greentree Health and Rehabilitation Center | 4.7 mi | Clintonville, WI | ★★★☆☆ | 3/5 | |
| Shawano Health Services | 7.1 mi | Shawano, WI | ★★★★☆ | 4/5 | |
| Evergreen Health Services | 7.4 mi | Shawano, WI | ★★☆☆☆ | 2/5 | |
| Birch Hill Health Services | 7.7 mi | Shawano, WI | ★★☆☆☆ | 3/5 | |
| Manawa Com Nur Ctr | 18.8 mi | Manawa, WI | ★☆☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 525497.