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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G4 | H· | I· |
| Potential harm | D31 | E19 | F18 |
| Minimal | A· | B· | C· |
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 21, 2026 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Mar 19, 2026 | Fire safety | Fire Safety Standard | 13 | Potential harm | — | Open → |
| Mar 19, 2026 | Health | Health Standard | 3 | Potential harm | — | Open → |
| Feb 16, 2026 | Health | Health Complaint | 1 | Immediate jeopardy | — | Open → |
| Dec 1, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 29, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jan 15, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 17, 2024 | Health | Health Complaint | 4 | Potential harm | — | Open → |
| Dec 5, 2024 | Fire safety | Fire Safety Standard | 13 | Potential harm | — | Open → |
| Dec 5, 2024 | Health | Health Complaint, Health Standard | 16 | Actual harm | — | Open → |
| Aug 1, 2024 | Health | Health Complaint | 3 | Actual harm | — | Open → |
| Jul 17, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Apr 16, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Sep 12, 2023 | Fire safety | Fire Safety Standard | 6 | Potential harm | — | Open → |
| Sep 12, 2023 | Health | Health Standard | 7 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Feb 16, 2026 | Civil money penalty (fine) | $24,845 | — | 525630|Fine|138203 |
| Dec 5, 2024 | Denial of payment for new admissions | — | Jan 3, 2025 · 29 days | 525630|Payment Denial|2025-01-03 |
| Dec 5, 2024 | Civil money penalty (fine) | $60,466 | — | 525630|Fine|61256 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G4 | H· | I· |
| Potential harm | D31 | E19 | F18 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Aug 21, 2026 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | G · Actual harm Isolated | Corrected Sep 14, 2026 | Complaint |
| Mar 19, 2026 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 9, 2026 | |
| Mar 19, 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.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Omnicare | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jun 5, 2025 |
| David Cunningham | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2024 |
| Mark Douma | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2023 |
| Mary Funseth | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2024 |
| Christine Kirsz | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 1, 2025 |
| Jill Klossner | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2023 |
| Karl Lueschow | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2024 |
| Patrick Meier | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 4, 2023 |
| Joan Moen | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2024 |
| David Rebedew | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jun 1, 2019 |
| Janis Roesslein | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2023 |
| Joann Shepherd | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Nov 1, 2024 |
| Matt Streiff | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 4, 2023 |
| David Wickline | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2022 |
| David Cunningham | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jun 1, 2023 |
| Mark Douma | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jul 1, 2024 |
| Mary Funseth | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jul 1, 2024 |
| Christine Kirsz | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2025 |
| Jill Klossner | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jul 1, 2023 |
| Karl Lueschow | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jul 1, 2024 |
| Patrick Meier | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jul 1, 2014 |
| Joan Moen | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jul 1, 2024 |
| David Rebedew | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jun 1, 2019 |
| Janis Roesslein | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jul 1, 2023 |
| Joann Shepherd | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Nov 1, 2024 |
| Matt Streiff | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 4, 2023 |
| David Wickline | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jun 1, 2023 |
| Gl Rehab | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jan 4, 2023 |
| Omnicare | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 1, 2025 |
| Wipfli LLP | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jan 4, 2023 |
| David Rebedew | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jan 4, 2023 |
| Joann Shepherd | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Nov 1, 2024 |
| Matt Streiff | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jan 4, 2023 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Four Winds Manor 303 S. Jefferson St., Verona, WI 53593 CCN 525656 | 20.8 km | 44 | Jul 23, 2026 | 541 harm | — | |
| Badger Prairie Hcc 1100 E Verona Ave, Verona, WI 53593 CCN 525516 | 21.6 km | 120 | Sep 10, 2025 | 16 | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 525630 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 525630 | 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
| E-0006 |
| Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness |
| F · Potential harm Widespread |
| Corrected Apr 9, 2026 |
| Mar 19, 2026 | E-0013 | Develop Emergency Preparedness policies and procedures. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 9, 2026 |
| Mar 19, 2026 | E-0025 | Create arrangements with other facilities to receive patients. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 6, 2026 |
| Mar 19, 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 Jun 1, 2026 |
| Mar 19, 2026 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 3, 2026 |
| Mar 19, 2026 | K-0331 | Construct fire resistant interior walls. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 20, 2026 |
| Mar 19, 2026 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 24, 2026 |
| Mar 19, 2026 | K-0347 | Properly provide smoke detection systems in areas open to corridors. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 13, 2026 |
| Mar 19, 2026 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 20, 2026 |
| Mar 19, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 20, 2026 |
| Mar 19, 2026 | 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 Mar 20, 2026 |
| Mar 19, 2026 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 20, 2026 |
| Mar 19, 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 15, 2026 |
| Mar 19, 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 19, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 15, 2026 |
| Feb 16, 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 | J · Immediate jeopardy Isolated | Past non-compliance Jan 19, 2026 | Complaint |
| Dec 1, 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 Jan 1, 2026 | Complaint |
| May 29, 2025 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Jun 29, 2025 | Complaint |
| May 29, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jun 29, 2025 | Complaint |
| Jan 15, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Feb 1, 2025 | Complaint |
| Dec 17, 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 Jan 10, 2025 | Complaint |
| Dec 17, 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 Jan 10, 2025 | Complaint |
| Dec 17, 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 Jan 10, 2025 | Complaint |
| Dec 17, 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 Jan 10, 2025 | Complaint |
| Dec 5, 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 1, 2025 |
| Dec 5, 2024 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Jan 3, 2025 |
| Dec 5, 2024 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 3, 2025 |
| Dec 5, 2024 | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 3, 2025 |
| Dec 5, 2024 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 3, 2025 |
| Dec 5, 2024 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 3, 2025 |
| Dec 5, 2024 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 3, 2025 |
| Dec 5, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 3, 2025 |
| Dec 5, 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 Jan 3, 2025 |
| Dec 5, 2024 | 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 Jan 3, 2025 |
| Dec 5, 2024 | K-0912 | Have power receptacles that are properly grounded. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 3, 2025 |
| Dec 5, 2024 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 3, 2025 |
| Dec 5, 2024 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 3, 2025 |
| Dec 5, 2024 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 3, 2025 |
| Dec 5, 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 Jan 3, 2025 |
| Dec 5, 2024 | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jan 3, 2025 | Complaint |
| Dec 5, 2024 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 3, 2025 |
| Dec 5, 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 Jan 3, 2025 | Complaint |
| Dec 5, 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 Jan 3, 2025 | Complaint |
| Dec 5, 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 Jan 3, 2025 | Complaint |
| Dec 5, 2024 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 3, 2025 | Complaint |
| Dec 5, 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 3, 2025 |
| Dec 5, 2024 | F-0742 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 3, 2025 |
| Dec 5, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 3, 2025 |
| Dec 5, 2024 | F-0802 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Jan 3, 2025 |
| Dec 5, 2024 | 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 | F · Potential harm Widespread | Corrected Jan 3, 2025 | Complaint |
| Dec 5, 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 Jan 3, 2025 | Complaint |
| Dec 5, 2024 | 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 Jan 3, 2025 |
| Dec 5, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Jan 3, 2025 |
| Aug 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 | G · Actual harm Isolated | Corrected Aug 16, 2024 | Complaint |
| Aug 1, 2024 | F-0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 16, 2024 | Complaint |
| Aug 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 16, 2024 | Complaint |
| Jul 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 | D · Potential harm Isolated | Corrected Aug 2, 2024 | Complaint |
| Apr 16, 2024 | F-0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected May 7, 2024 | Complaint |
| Sep 12, 2023 | K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 29, 2023 |
| Sep 12, 2023 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 29, 2023 |
| Sep 12, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 29, 2023 |
| Sep 12, 2023 | K-0379 | Have proper openings in smoke barrier doors. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 29, 2023 |
| Sep 12, 2023 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 29, 2023 |
| Sep 12, 2023 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 29, 2023 |
| Sep 12, 2023 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 29, 2023 |
| Sep 12, 2023 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 29, 2023 |
| Sep 12, 2023 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 29, 2023 |
| Sep 12, 2023 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Sep 29, 2023 |
| Sep 12, 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 Sep 29, 2023 |
| Sep 12, 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 | D · Potential harm Isolated | Corrected Sep 29, 2023 |
| Sep 12, 2023 | 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 Sep 27, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.67 (case-mix index 1.23).