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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J3 | K2 | L· |
| Actual harm | G6 | H· | I· |
| Potential harm | D50 | E33 | F23 |
| Minimal | A· | B· | C3 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Aug 25, 2026 | Health | Health Complaint | 1 | Potential harm | 1 | Open → |
| May 21, 2026 | Health | Health Complaint | 3 | Actual harm | — | Open → |
| Jul 9, 2025 | Health | Health Complaint | 1 | Minimal | — | Open → |
| May 1, 2025 | Fire safety | Fire Safety Standard | 16 | Potential harm | — | Open → |
| May 1, 2025 | Health | Health Complaint, Health Standard | 25 | Immediate jeopardy | — | Open → |
| Feb 13, 2025 | Health | Health Complaint | 8 | Immediate jeopardy | — | Open → |
| Nov 12, 2024 | Health | Health Complaint | 9 | Potential harm | — | Open → |
| May 29, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Apr 4, 2024 | Fire safety | Fire Safety Standard | 11 | Potential harm | — | Open → |
| Apr 4, 2024 | Health | Health Complaint, Health Standard | 8 | Potential harm | — | Open → |
| Jan 13, 2024 | Health | Health Complaint | 4 | Immediate jeopardy | — | Open → |
| Oct 12, 2023 | Health | Health Complaint | 7 | Actual harm | — | Open → |
| Dec 28, 2022 | Fire safety | Fire Safety Standard | 11 | Potential harm | — | Open → |
| Dec 28, 2022 | Health | Health Standard | 13 | Immediate jeopardy | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| May 1, 2025 | Civil money penalty (fine) | $94,803 | — | 525069|Fine|134509 |
| Feb 13, 2025 | Denial of payment for new admissions | — | Feb 28, 2025 · 5 days | 525069|Payment Denial|2025-02-28 |
| Feb 13, 2025 | Civil money penalty (fine) | $194,142 | — | 525069|Fine|61267 |
| Jan 13, 2024 | Civil money penalty (fine) | $14,053 | — | 525069|Fine|61087 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J3 | K2 | L· |
| Actual harm | G6 | H· | I· |
| Potential harm | D50 | E33 | F23 |
| Minimal | A· | B· | C3 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Aug 25, 2026 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Plan of correction, not yet verified Sep 23, 2026 | Complaint |
| May 21, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| New Horizon Foods, LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 15, 2024 |
| Rehab Solutions Group, LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2024 |
| David Affeldt | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Oct 24, 2014 |
| Richard Kellar | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Oct 24, 2014 |
| Susan Rabe | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Sep 24, 2019 |
| David Affeldt | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Oct 24, 2014 |
| A.v. Powell & Associates, LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 1, 2022 |
| Cliftonlarsonallen | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 21, 2016 |
| Favorite Healthcare Staffing LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Nov 30, 2020 |
| New Horizon Foods, LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | May 18, 2025 |
| Oak Medical Sc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 8, 2025 |
| Pharmacy Corporation of America | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jan 31, 2019 |
| Prn Health Services, Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jul 31, 2021 |
| R.w. Baird | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jan 12, 2015 |
| Raed Hamed Md LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Aug 1, 2017 |
| Rehab Solutions Group, LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | May 19, 2025 |
| Salonps Wisconsin | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 30, 2015 |
| Sikich LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 18, 2025 |
| David Affeldt | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Oct 24, 2014 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Clement Manor Health Care Center 3939 S 92nd St, Greenfield, WI 53228 CCN 525327 | 2 km | 50 | May 21, 2026 | 391 IJ1 harm | — | |
| Resolve at West Allis Respiratory and Rehab 9047 W Greenfield Ave, West Allis, WI 53214 CCN 525108 | 3 km | 152 | Aug 4, 2026 | 811 IJ4 harm | $130k | |
| Aria at Mitchell Manor 5301 W Lincoln Ave, West Allis, WI 53219 CCN 525600 | 3.7 km | 50 | Jul 1, 2026 | 451 IJ | — | |
| Sunrise Health Services 3540 S 43rd St, Milwaukee, WI 53220 CCN 525493 | 4.4 km | 99 | Feb 25, 2026 | 593 IJ | $114k | |
| Complete Care at Hales Corners 9449 W. Forest Home Ave., Hales Corners, WI 53130 CCN 525596 | 4.8 km | 62 | Feb 19, 2026 | 371 harm | $18k | |
| Lindengrove New Berlin 13755 W Fieldpointe Dr, New Berlin, WI 53151 CCN 525064 | 5.1 km | 110 | Jul 20, 2026 | 502 IJ3 harm | $100k | |
| Complete Care at Southpointe 4500 W. Loomis Rd., Greenfield, WI 53220 CCN 525604 | 5.4 km | 174 | Mar 12, 2026 | 452 IJ2 harm3 open | — | |
| St Camillus Health Center 10101 W Wisconsin Ave, Wauwatosa, WI 53226 CCN 525382 | 5.6 km | 50 | Jul 23, 2026 | 362 IJ | $66k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 525069 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 525069 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Corrected Jun 15, 2026 |
| Complaint |
| May 21, 2026 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 15, 2026 | Complaint |
| May 21, 2026 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 15, 2026 | Complaint |
| Jul 9, 2025 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected Aug 6, 2025 | Complaint |
| May 1, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | K · Immediate jeopardy Pattern | Corrected May 30, 2025 | Complaint |
| May 1, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected May 30, 2025 |
| May 1, 2025 | E-0007 | Address patient/client population and determine types of services needed. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected May 29, 2025 |
| May 1, 2025 | E-0013 | Develop Emergency Preparedness policies and procedures. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected May 29, 2025 |
| May 1, 2025 | K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. Construction Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 30, 2025 |
| May 1, 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. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 30, 2025 |
| May 1, 2025 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 24, 2025 |
| May 1, 2025 | K-0311 | Have an enclosure around a vertical opening shaft. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 29, 2025 |
| May 1, 2025 | K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 25, 2025 |
| May 1, 2025 | K-0347 | Properly provide smoke detection systems in areas open to corridors. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 22, 2025 |
| May 1, 2025 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 22, 2025 |
| May 1, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 24, 2025 |
| May 1, 2025 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 30, 2025 |
| May 1, 2025 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 30, 2025 |
| May 1, 2025 | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 20, 2025 |
| May 1, 2025 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 20, 2025 |
| May 1, 2025 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 23, 2025 |
| May 1, 2025 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 30, 2025 | Complaint |
| May 1, 2025 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 30, 2025 | Complaint |
| May 1, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 30, 2025 |
| May 1, 2025 | F-0685 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 30, 2025 |
| May 1, 2025 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 30, 2025 |
| May 1, 2025 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected May 30, 2025 | Complaint |
| May 1, 2025 | F-0726 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected May 30, 2025 | Complaint |
| May 1, 2025 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected May 30, 2025 |
| May 1, 2025 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected May 30, 2025 |
| May 1, 2025 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected May 30, 2025 | Complaint |
| May 1, 2025 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected May 30, 2025 |
| May 1, 2025 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected May 30, 2025 | Complaint |
| May 1, 2025 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected May 30, 2025 | Complaint |
| May 1, 2025 | F-0849 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected May 30, 2025 |
| May 1, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected May 30, 2025 |
| May 1, 2025 | F-0940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected May 30, 2025 |
| May 1, 2025 | F-0941 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected May 30, 2025 |
| May 1, 2025 | F-0942 | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected May 30, 2025 |
| May 1, 2025 | F-0944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected May 30, 2025 |
| May 1, 2025 | F-0945 | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected May 30, 2025 |
| May 1, 2025 | F-0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected May 30, 2025 |
| May 1, 2025 | F-0949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected May 30, 2025 |
| May 1, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Apr 24, 2025 |
| Feb 13, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected Mar 5, 2025 | Complaint |
| Feb 13, 2025 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | K · Immediate jeopardy Pattern | Corrected Mar 5, 2025 | Complaint |
| Feb 13, 2025 | F-0559 | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 5, 2025 | Complaint |
| Feb 13, 2025 | F-0560 | Protect a residents' right to refuse some types of non-requested transfers within the nursing home. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 5, 2025 | Complaint |
| Feb 13, 2025 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 5, 2025 | Complaint |
| Feb 13, 2025 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 5, 2025 | Complaint |
| Feb 13, 2025 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 5, 2025 | Complaint |
| Feb 13, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 5, 2025 | Complaint |
| Nov 12, 2024 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 10, 2024 | Complaint |
| Nov 12, 2024 | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 10, 2024 | Complaint |
| Nov 12, 2024 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 10, 2024 | Complaint |
| Nov 12, 2024 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 10, 2024 | Complaint |
| Nov 12, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 10, 2024 | Complaint |
| Nov 12, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 10, 2024 | Complaint |
| Nov 12, 2024 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Dec 10, 2024 | Complaint |
| Nov 12, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Dec 10, 2024 | Complaint |
| Nov 12, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Dec 10, 2024 | Complaint |
| May 29, 2024 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 29, 2024 | Complaint |
| May 29, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 29, 2024 | Complaint |
| May 29, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jun 29, 2024 | Complaint |
| Apr 4, 2024 | 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. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 22, 2024 |
| Apr 4, 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. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 22, 2024 |
| Apr 4, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 23, 2024 |
| Apr 4, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 22, 2024 |
| Apr 4, 2024 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 22, 2024 |
| Apr 4, 2024 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 22, 2024 |
| Apr 4, 2024 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 22, 2024 |
| Apr 4, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 22, 2024 |
| Apr 4, 2024 | K-0911 | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 22, 2024 |
| Apr 4, 2024 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 22, 2024 |
| Apr 4, 2024 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 2, 2024 |
| Apr 4, 2024 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 4, 2024 | Complaint |
| Apr 4, 2024 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 4, 2024 | Complaint |
| Apr 4, 2024 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 4, 2024 |
| Apr 4, 2024 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected May 4, 2024 | Complaint |
| Apr 4, 2024 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected May 4, 2024 |
| Apr 4, 2024 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected May 4, 2024 |
| Apr 4, 2024 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected May 4, 2024 |
| Apr 4, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected May 4, 2024 |
| Jan 13, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected Feb 9, 2024 | Complaint |
| Jan 13, 2024 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 9, 2024 | Complaint |
| Jan 13, 2024 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 9, 2024 | Complaint |
| Jan 13, 2024 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 9, 2024 | Complaint |
| Oct 12, 2023 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Nov 10, 2023 | Complaint |
| Oct 12, 2023 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Nov 10, 2023 | Complaint |
| Oct 12, 2023 | F-0578 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 10, 2023 | Complaint |
| Oct 12, 2023 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 10, 2023 | Complaint |
| Oct 12, 2023 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 10, 2023 | Complaint |
| Oct 12, 2023 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 10, 2023 | Complaint |
| Oct 12, 2023 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 10, 2023 | Complaint |
| Dec 28, 2022 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected Mar 7, 2023 |
| Dec 28, 2022 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Mar 7, 2023 |
| Dec 28, 2022 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Mar 7, 2023 |
| Dec 28, 2022 | K-0281 | Install proper backup exit lighting. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 20, 2023 |
| Dec 28, 2022 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 20, 2023 |
| Dec 28, 2022 | K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 20, 2023 |
| Dec 28, 2022 | K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 20, 2023 |
| Dec 28, 2022 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 20, 2023 |
| Dec 28, 2022 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 20, 2023 |
| Dec 28, 2022 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 20, 2023 |
| Dec 28, 2022 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 20, 2023 |
| Dec 28, 2022 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 20, 2023 |
| Dec 28, 2022 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 20, 2023 |
| Dec 28, 2022 | K-0919 | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 20, 2023 |
| Dec 28, 2022 | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Feb 7, 2023 |
| Dec 28, 2022 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 7, 2023 |
| Dec 28, 2022 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 7, 2023 |
| Dec 28, 2022 | F-0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 7, 2023 |
| Dec 28, 2022 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Feb 7, 2023 |
| Dec 28, 2022 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Feb 7, 2023 |
| Dec 28, 2022 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Mar 7, 2023 |
| Dec 28, 2022 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Feb 7, 2023 |
| Dec 28, 2022 | F-0888 | Ensure staff are vaccinated for COVID-19 Infection Control Deficiencies · Infection prevention | C · Minimal Widespread | Corrected Feb 7, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.67 (case-mix index 1.57).