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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G10 | H· | I· |
| Potential harm | D62 | E13 | F14 |
| 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 | |
|---|---|---|---|---|---|---|
| Jan 6, 2026 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Oct 29, 2025 | Health | Health Complaint | 9 | Actual harm | — | Open → |
| Aug 20, 2025 | Fire safety | Fire Safety Standard | 6 | Potential harm | — | Open → |
| Aug 20, 2025 | Health | Health Complaint, Health Standard | 14 | Potential harm | — | Open → |
| Jun 11, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Apr 1, 2025 | Health | Health Complaint | 11 | Actual harm | — | Open → |
| Dec 18, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Aug 28, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jul 22, 2024 | Fire safety | Fire Safety Standard | 11 | Potential harm | — | Open → |
| Jul 22, 2024 | Health | Health Complaint, Health Standard | 19 | Actual harm | — | Open → |
| Feb 28, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jan 17, 2024 | Health | Health Complaint | 8 | Immediate jeopardy | — | Open → |
| Oct 5, 2023 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Apr 1, 2023 | Fire safety | Fire Safety Standard | 6 | Potential harm | — | Open → |
| Apr 1, 2023 | Health | Health Standard | 7 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Jan 6, 2026 | Civil money penalty (fine) | $42,680 | — | 525552|Fine|137137 |
| Oct 29, 2025 | Civil money penalty (fine) | $56,400 | — | 525552|Fine|143623 |
| Apr 1, 2025 | Denial of payment for new admissions | — | May 2, 2025 · 4 days | 525552|Payment Denial|2025-05-02 |
| Apr 1, 2025 | Civil money penalty (fine) | $72,873 | — | 525552|Fine|134533 |
| Jul 22, 2024 | Denial of payment for new admissions | — | Aug 20, 2024 · 31 days | 525552|Payment Denial|2024-08-20 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G10 | H· | I· |
| Potential harm | D62 | E13 | F14 |
| Minimal | A· | B· | C3 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jan 6, 2026 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 4, 2026 | Complaint |
| Jan 6, 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 Feb 4, 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 2 facilities.
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 |
| Edgar Marthiens | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 16, 2022 |
| 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 |
| 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 |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Ascension Living - Lakeshore at Siena 5643 Erie Street, Racine, WI 53402 CCN 525495 | 60 | Feb 9, 2026 | 854 harm | $219k | |
| Franciscan Woods 19525 W North Ave, Brookfield, WI 53045 CCN 525528 | 110 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| St Ann Health and Rehabilitation Center 2020 S Muskego Ave, Milwaukee, WI 53204 CCN 525731 | 2.4 km | 50 | Mar 5, 2026 | 41 | — | |
| Sunrise Health Services 3540 S 43rd St, Milwaukee, WI 53220 CCN 525493 | 2.5 km | 99 | Feb 25, 2026 | 593 IJ | $114k | |
| Mercy Health Services 2727 W Mitchell St, Milwaukee, WI 53215 CCN 525414 | 3 km | 60 | Aug 17, 2026 | 582 harm7 open | $48k | |
| Aria at Mitchell Manor 5301 W Lincoln Ave, West Allis, WI 53219 CCN 525600 | 3.7 km | 50 | Jul 1, 2026 | 451 IJ | — | |
| Complete Care at Southpointe 4500 W. Loomis Rd., Greenfield, WI 53220 CCN 525604 | 4.1 km | 174 | Mar 12, 2026 | 452 IJ2 harm3 open | — | |
| St Francis Health Services 1915 E Tripoli Ave, Saint Francis, WI 53235 CCN 525477 | 4.6 km | 34 | Feb 18, 2026 | 341 harm | — | |
| Autumn Lake Healthcare at Greenfield 5790 S 27th St, Milwaukee, WI 53221 CCN 525504Abuse icon | 5.4 km | 112 | Jun 24, 2026 | 953 IJ7 harm12 open | $153k | |
| Greendale Park Nursing and Rehab 5404 W Loomis Rd, Greendale, WI 53129 CCN 525549 | 5.5 km | 105 | Jul 1, 2026 | 1291 IJ9 harm | $281k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 525552 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 525552 | 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
| Jul 22, 2024 | Civil money penalty (fine) | $71,858 | — | 525552|Fine|61191 |
| Jan 17, 2024 | Civil money penalty (fine) | $32,240 | — | 525552|Fine|61103 |
| Jan 6, 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 Mar 4, 2026 | Complaint |
| Oct 29, 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 | G · Actual harm Isolated | Corrected Nov 20, 2025 | Complaint |
| Oct 29, 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 Nov 20, 2025 | Complaint |
| Oct 29, 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 Nov 20, 2025 | Complaint |
| Oct 29, 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 Nov 20, 2025 | Complaint |
| Oct 29, 2025 | 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 Nov 20, 2025 | Complaint |
| Oct 29, 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 Nov 20, 2025 | Complaint |
| Oct 29, 2025 | 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 Nov 20, 2025 | Complaint |
| Oct 29, 2025 | 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 20, 2025 | Complaint |
| Oct 29, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Nov 20, 2025 | Complaint |
| Aug 20, 2025 | E-0030 | List the names and contact information of those in the facility. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Sep 17, 2025 |
| Aug 20, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 17, 2025 |
| Aug 20, 2025 | K-0753 | Have restrictions on the use of highly flammable decorations. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 17, 2025 |
| Aug 20, 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 Sep 17, 2025 |
| Aug 20, 2025 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Sep 17, 2025 |
| Aug 20, 2025 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 17, 2025 |
| Aug 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 Sep 17, 2025 | Complaint |
| Aug 20, 2025 | 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 | E · Potential harm Pattern | Corrected Sep 17, 2025 |
| Aug 20, 2025 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 17, 2025 |
| Aug 20, 2025 | 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 Sep 17, 2025 |
| Aug 20, 2025 | 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 17, 2025 |
| Aug 20, 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 Sep 17, 2025 | Complaint |
| Aug 20, 2025 | 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 Sep 17, 2025 |
| Aug 20, 2025 | F-0729 | Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Sep 17, 2025 |
| Aug 20, 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 | F · Potential harm Widespread | Corrected Sep 17, 2025 | Complaint |
| Aug 20, 2025 | 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 | E · Potential harm Pattern | Corrected Sep 17, 2025 |
| Aug 20, 2025 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Sep 17, 2025 | Complaint |
| Aug 20, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Sep 17, 2025 |
| Aug 20, 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 | C · Minimal Widespread | Corrected Sep 17, 2025 |
| Aug 20, 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 | C · Minimal Widespread | Corrected Sep 17, 2025 |
| Jun 11, 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 Jul 10, 2025 | Complaint |
| Jun 11, 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 Jul 10, 2025 | Complaint |
| Apr 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 6, 2025 | Complaint |
| Apr 1, 2025 | 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 | G · Actual harm Isolated | Corrected May 6, 2025 | Complaint |
| Apr 1, 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 May 6, 2025 | Complaint |
| Apr 1, 2025 | 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 6, 2025 | Complaint |
| Apr 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 | E · Potential harm Pattern | Corrected May 6, 2025 | Complaint |
| Apr 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 | D · Potential harm Isolated | Corrected May 6, 2025 | Complaint |
| Apr 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 6, 2025 | Complaint |
| Apr 1, 2025 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected May 6, 2025 | Complaint |
| Apr 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 6, 2025 | Complaint |
| Apr 1, 2025 | F-0773 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected May 6, 2025 | Complaint |
| Apr 1, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected May 6, 2025 | Complaint |
| Dec 18, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 16, 2025 | Complaint |
| Aug 28, 2024 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 20, 2024 | Complaint |
| Aug 28, 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 Sep 20, 2024 | Complaint |
| Jul 22, 2024 | 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 Aug 19, 2024 | Complaint |
| Jul 22, 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 Aug 19, 2024 |
| Jul 22, 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 Aug 19, 2024 | Complaint |
| Jul 22, 2024 | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Aug 19, 2024 |
| Jul 22, 2024 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Aug 19, 2024 |
| Jul 22, 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 Aug 19, 2024 |
| Jul 22, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 19, 2024 |
| Jul 22, 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 Aug 19, 2024 |
| Jul 22, 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 Aug 19, 2024 |
| Jul 22, 2024 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Waiver granted Nov 8, 2024 |
| Jul 22, 2024 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 19, 2024 |
| Jul 22, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 19, 2024 |
| Jul 22, 2024 | 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 Aug 19, 2024 |
| Jul 22, 2024 | K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 19, 2024 |
| Jul 22, 2024 | 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 Aug 19, 2024 | Complaint |
| Jul 22, 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 Aug 19, 2024 |
| Jul 22, 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 19, 2024 | Complaint |
| Jul 22, 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 19, 2024 | Complaint |
| Jul 22, 2024 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 19, 2024 |
| Jul 22, 2024 | F-0638 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 19, 2024 |
| Jul 22, 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 Aug 19, 2024 |
| Jul 22, 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 Aug 19, 2024 |
| Jul 22, 2024 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 20, 2024 |
| Jul 22, 2024 | 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 | E · Potential harm Pattern | Corrected Aug 19, 2024 |
| Jul 22, 2024 | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 19, 2024 |
| Jul 22, 2024 | F-0810 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Aug 19, 2024 |
| Jul 22, 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 Aug 19, 2024 |
| Jul 22, 2024 | 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 Aug 19, 2024 |
| Jul 22, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Aug 19, 2024 |
| Feb 28, 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 Mar 4, 2024 | Complaint |
| Jan 17, 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 16, 2024 | Complaint |
| Jan 17, 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 | G · Actual harm Isolated | Corrected Feb 16, 2024 | Complaint |
| Jan 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 | G · Actual harm Isolated | Corrected Feb 16, 2024 | Complaint |
| Jan 17, 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 Feb 16, 2024 | Complaint |
| Jan 17, 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 | G · Actual harm Isolated | Corrected Feb 16, 2024 | Complaint |
| Jan 17, 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 Feb 16, 2024 | Complaint |
| Jan 17, 2024 | F-0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 16, 2024 | Complaint |
| Jan 17, 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 | D · Potential harm Isolated | Corrected Feb 16, 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 | D · Potential harm Isolated | Corrected Nov 5, 2023 | Complaint |
| Oct 5, 2023 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 5, 2023 | Complaint |
| Oct 5, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Nov 5, 2023 | Complaint |
| Apr 1, 2023 | K-0281 | Install proper backup exit lighting. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 4, 2023 |
| Apr 1, 2023 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 4, 2023 |
| Apr 1, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 4, 2023 |
| Apr 1, 2023 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 4, 2023 |
| Apr 1, 2023 | 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 4, 2023 |
| Apr 1, 2023 | 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 4, 2023 |
| Apr 1, 2023 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 18, 2023 |
| Apr 1, 2023 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 18, 2023 |
| Apr 1, 2023 | F-0637 | Assess the resident when there is a significant change in condition Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 18, 2023 |
| Apr 1, 2023 | F-0638 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 18, 2023 |
| Apr 1, 2023 | 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 18, 2023 |
| Apr 1, 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 | D · Potential harm Isolated | Corrected May 18, 2023 |
| Apr 1, 2023 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected May 18, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.15 (case-mix index 1.38).
| Erin Shadbolt |
| Individual |
| Corporate officer / director |
| CORPORATE DIRECTOR |
| not provided |
| Jan 1, 2024 |
| Kenneth Smoot | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2024 |
| Ascension Health Senior Care | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jul 1, 2015 |
| House Healthcare Solutions LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jun 10, 2025 |
| 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 | Apr 8, 2024 |
| Michael Porter | Organization | Additional disclosable party | ADP OF THE SNF | not provided | May 9, 2021 |
| Nursing Centers, Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jun 3, 2025 |
| Edgar Marthiens | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 16, 2022 |
| 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 |
| Jul 23, 2026 |
716 harm2 open |
| $203k |