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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G5 | H· | I· |
| Potential harm | D66 | E28 | F21 |
| Minimal | A· | B· | C1 |
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 12, 2026 | Health | Health Complaint | 3 | Actual harm | — | Open → |
| Apr 14, 2026 | Health | Health Complaint | 6 | Actual harm | — | Open → |
| Mar 12, 2026 | Fire safety | Fire Safety Standard | 16 | Potential harm | — | Open → |
| Mar 12, 2026 | Health | Health Complaint, Health Standard | 13 | Actual harm | — | Open → |
| Feb 3, 2026 | Health | Health Complaint | 6 | Potential harm | — | Open → |
| Jan 8, 2026 | Health | Health Complaint | 4 | Potential harm | — | Open → |
| Dec 4, 2025 | Health | Health Complaint | 4 | Potential harm | — | Open → |
| Jul 28, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Mar 20, 2025 | Health | Health Complaint | 5 | Potential harm | — | Open → |
| Dec 3, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Oct 7, 2024 | Fire safety | Fire Safety Standard | 10 | Potential harm | — | Open → |
| Oct 7, 2024 | Health | Health Complaint, Health Standard | 12 | Actual harm | — | Open → |
| Jul 1, 2024 | Health | Health Complaint | 19 | Immediate jeopardy | — | Open → |
| Apr 8, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Aug 9, 2023 | Fire safety | Fire Safety Standard | 13 | Potential harm | — | Open → |
| Aug 9, 2023 | Health | Health Standard | 6 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Mar 12, 2026 | Civil money penalty (fine) | $51,150 | — | 525523|Fine|144379 |
| Oct 7, 2024 | Denial of payment for new admissions | — | Nov 6, 2024 · 51 days | 525523|Payment Denial|2024-11-06 |
| Oct 7, 2024 | Civil money penalty (fine) | $74,120 | — | 525523|Fine|61225 |
| Jul 1, 2024 | Denial of payment for new admissions | — | Jul 30, 2024 · 22 days | 525523|Payment Denial|2024-07-30 |
| Jul 1, 2024 | Civil money penalty (fine) | $16,801 | — | 525523|Fine|61177 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G5 | H· | I· |
| Potential harm | D66 | E28 | F21 |
| Minimal | A· | B· | C1 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Aug 12, 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 | Past non-compliance Jun 26, 2026 | Complaint |
| Aug 12, 2026 | 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 Sep 5, 2026 | Complaint |
“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.
10 facilities in 1 states. CMS chain ID 819.
Chain average overall rating (CMS): 2.2
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Axis Holdings LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Oct 1, 2025 |
| Topper Family 2024 Trust | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Oct 1, 2025 |
| Akiva Brandman | Individual | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Oct 1, 2025 |
| Yaakov Brandman | Individual | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Oct 1, 2025 |
| Igor Rebel | Individual | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Oct 1, 2025 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Axis Holdings LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Oct 1, 2025 |
| Topper Family 2024 Trust | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Oct 1, 2025 |
| Akiva Brandman | Individual | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Oct 1, 2025 |
| Yaakov Brandman | Individual | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Oct 1, 2025 |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Avina of Kenosha 3100 Washington Rd., Kenosha, WI 53144 CCN 525179 | 153 | Aug 20, 2026 | 905 IJ3 harm4 open | $34k | |
| Avina of Fond Du Lac |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Amethyst Health of Brown Deer 7500 W Dean Rd, Milwaukee, WI 53223 CCN 525498SFF Candidate | 1.8 km | 87 | May 20, 2026 | 1163 IJ4 harm1 open | $331k | |
| Bradley Estates Nursing and Rehab LLC 6735 W Bradley Rd, Milwaukee, WI 53223 CCN 525325SFF CandidateAbuse icon | 2.8 km | 198 | Jul 9, 2026 | 1903 IJ11 harm | $305k | |
| Newcastle Place 12600 N Port Washington Rd #300, Mequon, WI 53092 CCN 525668 | 5.8 km | 47 | May 20, 2026 | 621 IJ1 harm | $8,281 | |
| Complete Care at Glendale West 6263 N Green Bay Ave, Glendale, WI 53209 CCN 525547 | 8.5 km | 94 | Nov 12, 2025 | 651 IJ1 harm | $11k | |
| Luther Manor 4545 N 92nd St, Milwaukee, WI 53225 CCN 525588 | 9.7 km | 99 | Jul 29, 2026 | 853 IJ4 harm1 open | $164k | |
| Bayshore Nursing & Rehab 1300 West Silver Spring Dr, Glendale, WI 53209 CCN 525371SFF CandidateAbuse icon | 9.9 km | 112 | Apr 30, 2026 | 1797 IJ3 harm1 open | $424k | |
| Menomonee Falls Health Services N84 W17049 Menomonee Ave, Menomonee Falls, WI 53051 CCN 525415 | 10.2 km | 50 | Dec 3, 2025 | 725 harm | $214k | |
| Lindengrove Menomonee Falls W180 N8071 Town Hall Rd, Menomonee Falls, WI 53051 CCN 525421 | 10.2 km | 73 | Jul 23, 2026 | 773 IJ3 harm1 open | $194k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 525523 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 525523 | 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
| Aug 12, 2026 | 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 Sep 5, 2026 | Complaint |
| Apr 14, 2026 | 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 | G · Actual harm Isolated | Corrected May 2, 2026 | Complaint |
| Apr 14, 2026 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 2, 2026 | Complaint |
| Apr 14, 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 May 2, 2026 | Complaint |
| Apr 14, 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 May 2, 2026 | Complaint |
| Apr 14, 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 May 2, 2026 | Complaint |
| Apr 14, 2026 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected May 2, 2026 | Complaint |
| Mar 12, 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 8, 2026 | Complaint |
| Mar 12, 2026 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 8, 2026 |
| Mar 12, 2026 | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 8, 2026 |
| Mar 12, 2026 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 8, 2026 |
| Mar 12, 2026 | 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 8, 2026 |
| Mar 12, 2026 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 27, 2026 |
| Mar 12, 2026 | 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 Apr 8, 2026 |
| Mar 12, 2026 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 8, 2026 |
| Mar 12, 2026 | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 8, 2026 |
| Mar 12, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 8, 2026 |
| Mar 12, 2026 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 8, 2026 |
| Mar 12, 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 Apr 8, 2026 |
| Mar 12, 2026 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 8, 2026 |
| Mar 12, 2026 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 8, 2026 |
| Mar 12, 2026 | K-0753 | Have restrictions on the use of highly flammable decorations. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 8, 2026 |
| Mar 12, 2026 | 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 8, 2026 |
| Mar 12, 2026 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 8, 2026 |
| Mar 12, 2026 | 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 | E · Potential harm Pattern | Corrected Apr 8, 2026 |
| Mar 12, 2026 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 8, 2026 |
| Mar 12, 2026 | 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 Apr 8, 2026 |
| Mar 12, 2026 | 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 Apr 8, 2026 |
| Mar 12, 2026 | 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 Apr 8, 2026 |
| Mar 12, 2026 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Apr 8, 2026 |
| Mar 12, 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 | D · Potential harm Isolated | Corrected Apr 8, 2026 |
| Mar 12, 2026 | F-0809 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Apr 8, 2026 |
| Mar 12, 2026 | 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 Apr 8, 2026 |
| Mar 12, 2026 | F-0825 | Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 8, 2026 |
| Mar 12, 2026 | 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 Apr 8, 2026 |
| Mar 12, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 8, 2026 |
| Feb 3, 2026 | F-0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 3, 2026 | Complaint |
| Feb 3, 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 3, 2026 | Complaint |
| Feb 3, 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 3, 2026 | Complaint |
| Feb 3, 2026 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 3, 2026 | Complaint |
| Feb 3, 2026 | 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 Mar 3, 2026 | Complaint |
| Feb 3, 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 | D · Potential harm Isolated | Corrected Mar 3, 2026 | Complaint |
| Jan 8, 2026 | 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 Feb 8, 2026 | Complaint |
| Jan 8, 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 | D · Potential harm Isolated | Corrected Feb 8, 2026 | Complaint |
| Jan 8, 2026 | 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 Feb 8, 2026 | Complaint |
| Jan 8, 2026 | F-0909 | Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 8, 2026 | Complaint |
| Dec 4, 2025 | 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 Jan 4, 2026 | Complaint |
| Dec 4, 2025 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 4, 2026 | Complaint |
| Dec 4, 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 | D · Potential harm Isolated | Corrected Jan 4, 2026 | Complaint |
| Dec 4, 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 Jan 4, 2026 | Complaint |
| Jul 28, 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 Aug 28, 2025 | Complaint |
| Jul 28, 2025 | F-0740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 18, 2025 | Complaint |
| Mar 20, 2025 | 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 Apr 20, 2025 | Complaint |
| Mar 20, 2025 | 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 Apr 20, 2025 | Complaint |
| Mar 20, 2025 | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 20, 2025 | Complaint |
| Mar 20, 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 Apr 20, 2025 | Complaint |
| Mar 20, 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 Apr 20, 2025 | Complaint |
| Dec 3, 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 20, 2024 | Complaint |
| Dec 3, 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 | E · Potential harm Pattern | Corrected Dec 20, 2024 | Complaint |
| Oct 7, 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 Nov 5, 2024 |
| Oct 7, 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 | G · Actual harm Isolated | Corrected Dec 20, 2024 | Complaint |
| Oct 7, 2024 | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Dec 10, 2024 |
| Oct 7, 2024 | E-0013 | Develop Emergency Preparedness policies and procedures. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Dec 10, 2024 |
| Oct 7, 2024 | E-0035 | Provide family notifications of emergency plan. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Nov 6, 2024 |
| Oct 7, 2024 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 27, 2024 |
| Oct 7, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Waiver granted Mar 26, 2025 |
| Oct 7, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 29, 2024 |
| Oct 7, 2024 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 29, 2024 |
| Oct 7, 2024 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 10, 2024 |
| Oct 7, 2024 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 29, 2024 |
| Oct 7, 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 20, 2024 | Complaint |
| Oct 7, 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 5, 2024 | Complaint |
| Oct 7, 2024 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 5, 2024 |
| Oct 7, 2024 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 5, 2024 |
| Oct 7, 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 Nov 5, 2024 |
| Oct 7, 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 Nov 5, 2024 |
| Oct 7, 2024 | 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 Nov 5, 2024 |
| Oct 7, 2024 | 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 Nov 5, 2024 |
| Oct 7, 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 Nov 5, 2024 |
| Oct 7, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Nov 5, 2024 |
| Oct 7, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Nov 29, 2024 |
| Jul 1, 2024 | 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 Aug 21, 2024 | Complaint |
| Jul 1, 2024 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 6, 2024 | Complaint |
| Jul 1, 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 Aug 6, 2024 | Complaint |
| Jul 1, 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 Aug 6, 2024 | Complaint |
| Jul 1, 2024 | F-0687 | Provide appropriate foot care. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 6, 2024 | Complaint |
| Jul 1, 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 Aug 6, 2024 | Complaint |
| Jul 1, 2024 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Aug 6, 2024 | Complaint |
| Jul 1, 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 Aug 6, 2024 | Complaint |
| Jul 1, 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 Aug 6, 2024 | Complaint |
| Jul 1, 2024 | F-0887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Aug 6, 2024 | Complaint |
| Jul 1, 2024 | F-0940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Aug 6, 2024 | Complaint |
| Jul 1, 2024 | F-0941 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Aug 6, 2024 | Complaint |
| Jul 1, 2024 | 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 Aug 6, 2024 | Complaint |
| Jul 1, 2024 | F-0943 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 6, 2024 | Complaint |
| Jul 1, 2024 | 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 Aug 6, 2024 | Complaint |
| Jul 1, 2024 | 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 Aug 6, 2024 | Complaint |
| Jul 1, 2024 | F-0946 | Provide training in compliance and ethics. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Aug 6, 2024 | Complaint |
| Jul 1, 2024 | 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 | E · Potential harm Pattern | Corrected Aug 6, 2024 | Complaint |
| Jul 1, 2024 | 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 Aug 6, 2024 | Complaint |
| Apr 8, 2024 | F-0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected May 7, 2024 | Complaint |
| Aug 9, 2023 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Sep 28, 2023 |
| Aug 9, 2023 | 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 Sep 9, 2023 |
| Aug 9, 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 Sep 9, 2023 |
| Aug 9, 2023 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 9, 2023 |
| Aug 9, 2023 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 18, 2023 |
| Aug 9, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 9, 2023 |
| Aug 9, 2023 | 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 Sep 9, 2023 |
| Aug 9, 2023 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 9, 2023 |
| Aug 9, 2023 | K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 9, 2023 |
| Aug 9, 2023 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 9, 2023 |
| Aug 9, 2023 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 9, 2023 |
| Aug 9, 2023 | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 9, 2023 |
| Aug 9, 2023 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 9, 2023 |
| Aug 9, 2023 | 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 Sep 9, 2023 |
| Aug 9, 2023 | 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 | D · Potential harm Isolated | Corrected Sep 9, 2023 |
| Aug 9, 2023 | F-0625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 9, 2023 |
| Aug 9, 2023 | 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 Sep 9, 2023 |
| Aug 9, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Sep 9, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.61 (case-mix index 1.56).
| Igor Rebel | Individual | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Oct 1, 2025 |
| Aaron Topper | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Oct 1, 2025 |
| Sarfraz Sidhu | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Oct 1, 2015 |
| Elsie Smith | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Oct 1, 2025 |
| Aaron Topper | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Oct 1, 2025 |
| Topper Family 2024 Trust | Organization | Trustee | TRUSTEE OF THE SNF | not provided | Oct 1, 2025 |
| Cecilia Topper | Individual | Trustee | TRUSTEE OF THE SNF | not provided | Oct 1, 2025 |
| Axis Holdings LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Oct 1, 2025 |
| Igor Rebel | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Oct 1, 2025 |
| Sarfraz Sidhu | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Oct 1, 2015 |
| Elsie Smith | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Oct 1, 2025 |
| Cecilia Topper | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Oct 1, 2025 |
| 50 |
| Jul 6, 2026 |
651 IJ |
| $7,446 |
| Avina on 32nd 8633 32nd Ave, Kenosha, WI 53142 CCN 525282Abuse icon | 110 | Jun 30, 2026 | 731 IJ | $26k |
| Avina of Sun Prairie 41 Rickel Rd., Sun Prairie, WI 53590 CCN 525313 | 50 | Aug 5, 2026 | 35 | — |
| Avina of Weyauwega 717 E Alfred St, Weyauwega, WI 54983 CCN 525315 | 84 | Jul 1, 2026 | 793 IJ2 harm | $116k |
| Milwaukee Health and Rehab 3216 W Highland Blvd, Milwaukee, WI 53208 CCN 525417 | 95 | Dec 8, 2025 | 60 | — |
| Avina on Division 517 E Division St, Fond Du Lac, WI 54935 CCN 525522 | 50 | Aug 5, 2026 | 591 IJ2 harm | $58k |
| Avina of Mayville 305 S. Clark St., Mayville, WI 53050 CCN 525616 | 80 | Jun 17, 2026 | 531 harm | $19k |