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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G3 | H1 | I· |
| Potential harm | D43 | E17 | F18 |
| 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 | |
|---|---|---|---|---|---|---|
| Feb 9, 2026 | Fire safety | Fire Safety Standard | 8 | Potential harm | — | Open → |
| Feb 9, 2026 | Health | Health Complaint, Health Standard | 27 | Actual harm | — | Open → |
| Jul 21, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| May 30, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 11, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 26, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Sep 23, 2024 | Fire safety | Fire Safety Standard | 16 | Potential harm | — | Open → |
| Sep 23, 2024 | Health | Health Complaint, Health Standard | 8 | Actual harm | — | Open → |
| Apr 17, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Jan 23, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Oct 5, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jun 22, 2023 | Fire safety | Fire Safety Standard | 4 | Potential harm | — | Open → |
| Jun 22, 2023 | Health | Health Standard | 10 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Feb 9, 2026 | Denial of payment for new admissions | — | Mar 11, 2026 · 47 days | 525495|Payment Denial|2026-03-11 |
| Feb 9, 2026 | Civil money penalty (fine) | $218,735 | — | 525495|Fine|144314 |
| Sep 23, 2024 | Denial of payment for new admissions | — | Oct 26, 2024 · 19 days | 525495|Payment Denial|2024-10-26 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G3 | H1 | I· |
| Potential harm | D43 | E17 | F18 |
| Minimal | A· | B· | C3 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Feb 9, 2026 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | H · Actual harm Pattern | Corrected Apr 27, 2026 | |
| Feb 9, 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 Apr 27, 2026 | Complaint |
| Feb 9, 2026 |
“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.
12 facilities in 8 states. CMS chain ID 48.
Chain average overall rating (CMS): 2.9
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Ascension Health Senior Care | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Jul 1, 2014 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Ascension Health Senior Care | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Jul 1, 2014 |
| Olusola Ajayi | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 19, 2025 |
| Sarfraz Sidhu | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 1, 2025 |
| Lisa Musgrave | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2024 |
| Erin Shadbolt |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Franciscan Woods 19525 W North Ave, Brookfield, WI 53045 CCN 525528 | 110 | Jul 23, 2026 | 716 harm2 open | $203k | |
| Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St, Milwaukee, WI 53215 CCN 525552 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Lincoln Park Nursing and Rehab LLC 1700 C a Becker Dr, Racine, WI 53406 CCN 525061 | 10.5 km | 122 | Apr 22, 2026 | 622 IJ3 harm2 open | $183k | |
| Complete Care at Ridgewood LLC 3205 Wood Rd, Racine, WI 53406 CCN 525608 | 11.9 km | 200 | Apr 7, 2026 | 671 harm | — | |
| Willowcrest Health Services 3821 S Chicago Ave, South Milwaukee, WI 53172 CCN 525413 | 12.8 km | 100 | Jun 5, 2025 | 652 IJ | $21k | |
| Chi Franciscan Villa 3601 S Chicago Ave, South Milwaukee, WI 53172 CCN 525526 | 13.1 km | 90 | May 29, 2026 | 933 IJ5 harm | $323k | |
| Medical Suites at Oak Creek (the) 2700 Honadel Boulevard, Oak Creek, WI 53154 CCN 525730SFF | 17.2 km | 144 | Not rated | May 19, 2026 | 1549 IJ1 harm | $199k |
| Waters Edge Health and Rehabilitation Center 3415 N Sheridan Rd, Kenosha, WI 53140 CCN 525281Abuse icon | 21 km | 128 | Jun 11, 2026 | 1004 IJ4 harm | $370k | |
| Avina of Kenosha 3100 Washington Rd., Kenosha, WI 53144 CCN 525179 | 21.9 km | 153 | Aug 20, 2026 | 905 IJ3 harm4 open | $34k | |
| Brookside Care Center 3506 Washington Rd, Kenosha, WI 53144 CCN 525556 | 21.9 km | 154 | Jun 18, 2026 | 202 harm | $45k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 525495 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 525495 | 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
| F-0744 |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Clinical care |
| G · Actual harm Isolated |
| Corrected Mar 31, 2026 |
| Feb 9, 2026 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 10, 2026 |
| Feb 9, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 10, 2026 |
| Feb 9, 2026 | 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 Mar 20, 2026 |
| Feb 9, 2026 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 10, 2026 |
| Feb 9, 2026 | K-0753 | Have restrictions on the use of highly flammable decorations. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 10, 2026 |
| Feb 9, 2026 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 3, 2026 |
| Feb 9, 2026 | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 10, 2026 |
| Feb 9, 2026 | 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 Mar 10, 2026 |
| Feb 9, 2026 | 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 | D · Potential harm Isolated | Corrected Mar 31, 2026 |
| Feb 9, 2026 | 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 Mar 31, 2026 |
| Feb 9, 2026 | F-0606 | Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Mar 31, 2026 |
| Feb 9, 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 Mar 31, 2026 | Complaint |
| Feb 9, 2026 | 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 31, 2026 | Complaint |
| Feb 9, 2026 | F-0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 31, 2026 |
| Feb 9, 2026 | 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 | E · Potential harm Pattern | Corrected Mar 31, 2026 |
| Feb 9, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 31, 2026 | Complaint |
| Feb 9, 2026 | 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 Mar 31, 2026 |
| Feb 9, 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 Mar 31, 2026 |
| Feb 9, 2026 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 31, 2026 |
| Feb 9, 2026 | 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 | E · Potential harm Pattern | Corrected Mar 31, 2026 | Complaint |
| Feb 9, 2026 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 31, 2026 |
| Feb 9, 2026 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 31, 2026 |
| Feb 9, 2026 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 31, 2026 | Complaint |
| Feb 9, 2026 | 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 Mar 31, 2026 |
| Feb 9, 2026 | 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 | F · Potential harm Widespread | Corrected Mar 31, 2026 |
| Feb 9, 2026 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Mar 31, 2026 |
| Feb 9, 2026 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Mar 31, 2026 |
| Feb 9, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Mar 31, 2026 |
| Feb 9, 2026 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Mar 31, 2026 |
| Feb 9, 2026 | F-0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Mar 31, 2026 |
| Feb 9, 2026 | 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 Mar 31, 2026 |
| Feb 9, 2026 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected Mar 31, 2026 | Complaint |
| Jul 21, 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 Aug 8, 2025 | Complaint |
| Jul 21, 2025 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 8, 2025 | Complaint |
| May 30, 2025 | 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 19, 2025 | Complaint |
| Feb 11, 2025 | 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 Mar 7, 2025 | Complaint |
| Dec 26, 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 Jan 21, 2025 | Complaint |
| Dec 26, 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 Jan 21, 2025 | Complaint |
| Sep 23, 2024 | 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 Oct 23, 2024 | Complaint |
| Sep 23, 2024 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 19, 2024 |
| Sep 23, 2024 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 23, 2024 |
| Sep 23, 2024 | K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 23, 2024 |
| Sep 23, 2024 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 23, 2024 |
| Sep 23, 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 Oct 21, 2024 |
| Sep 23, 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 Oct 23, 2024 |
| Sep 23, 2024 | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 14, 2024 |
| Sep 23, 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 Oct 23, 2024 |
| Sep 23, 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 Oct 23, 2024 |
| Sep 23, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 23, 2024 |
| Sep 23, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 29, 2024 |
| Sep 23, 2024 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 23, 2024 |
| Sep 23, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 23, 2024 |
| Sep 23, 2024 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 23, 2024 |
| Sep 23, 2024 | 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 Oct 21, 2024 |
| Sep 23, 2024 | F-0563 | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 1, 2024 | Complaint |
| Sep 23, 2024 | 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 1, 2024 |
| Sep 23, 2024 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 23, 2024 | Complaint |
| Sep 23, 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 Nov 1, 2024 | Complaint |
| Sep 23, 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 Nov 1, 2024 | Complaint |
| Sep 23, 2024 | F-0745 | Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 1, 2024 | Complaint |
| Sep 23, 2024 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 23, 2024 | Complaint |
| Sep 23, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Oct 16, 2024 |
| Apr 17, 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 May 14, 2024 | Complaint |
| Apr 17, 2024 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 14, 2024 | Complaint |
| Apr 17, 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 May 14, 2024 | Complaint |
| Jan 23, 2024 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 7, 2024 | Complaint |
| Jan 23, 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 Mar 7, 2024 | Complaint |
| Oct 5, 2023 | 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 | E · Potential harm Pattern | Corrected Nov 9, 2023 | Complaint |
| Jun 22, 2023 | 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 Jun 21, 2023 |
| Jun 22, 2023 | 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 Jul 11, 2023 |
| Jun 22, 2023 | K-0919 | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 21, 2023 |
| Jun 22, 2023 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 11, 2023 |
| Jun 22, 2023 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 7, 2023 |
| Jun 22, 2023 | F-0661 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 26, 2023 |
| Jun 22, 2023 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 20, 2023 |
| Jun 22, 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 | D · Potential harm Isolated | Corrected Jul 26, 2023 |
| Jun 22, 2023 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 26, 2023 |
| Jun 22, 2023 | 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 | E · Potential harm Pattern | Corrected Jul 26, 2023 |
| Jun 22, 2023 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jul 20, 2023 |
| Jun 22, 2023 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Jul 20, 2023 |
| Jun 22, 2023 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected Jul 15, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.88 (case-mix index 1.49).
| Individual |
| Corporate officer / director |
| CORPORATE DIRECTOR |
| not provided |
| Jan 1, 2024 |
| Kenneth Smoot | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2024 |
| Erin Shadbolt | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Oct 17, 2022 |
| Ascension Health Senior Care | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jul 14, 2015 |
| Health Dimensions Consulting Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Aug 2, 2019 |
| House Healthcare Solutions LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jun 10, 2025 |
| Intelycare Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Feb 8, 2022 |
| Medical Solutions LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jun 14, 2017 |
| Metis Ltc LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Sep 2, 2024 |
| Personnel Specialists LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 10, 2025 |
| Prolink Healthcare LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 26, 2023 |
| Olusola Ajayi | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 19, 2025 |
| Lisa Musgrave | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2024 |
| Erin Shadbolt | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2024 |
| Sarfraz Sidhu | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2025 |
| Kenneth Smoot | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2024 |
| 81 |
| Jan 6, 2026 |
1031 IJ10 harm |
| $276k |