Cycle 1
Health 2025-02-20 · Fire 2025-02-20
20 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
South Milwaukee, WI
Chi Franciscan Villa
1-star overall rating with 1-star inspections with abuse icon flag with $271,775 in total fines with 20 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
3601 S Chicago Ave, South Milwaukee, WI
(414) 764-4100
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
86
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Commonspirit Health
Operator or chain grouping
Approved since
1993-11-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.07
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
2.92
CMS adjusted total nurse staffing hours
Case-mix index
1.67
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.09% · Performance 22.13% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.33% · Performance 8.31% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 2.88 hours · Performance 2.63 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.66% |
10.72%
3.9 pts worse
|
Worse than the National Rate · Eligible stays 134 · Observed rate 23.13% · Lower 95% interval 11.44% |
| Discharge to community | 38.22% |
50.57%
12.4 pts worse
|
Worse than the National Rate · Eligible stays 105 · Observed rate 29.52% · Lower 95% interval 27.95% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.75% |
95.27%
2.5 pts better
|
Numerator 87 · Denominator 89 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 89 |
| Discharge self-care score | 82.98% |
53.69%
29.3 pts better
|
Numerator 39 · Denominator 47 |
| Discharge mobility score | 80.85% |
50.94%
29.9 pts better
|
Numerator 38 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 1.12% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 89 · Adjusted rate 1.08% |
| Healthcare-associated infections requiring hospitalization | 8.31% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 102 · Observed rate 11.76% · Lower 95% interval 4.48% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 235 |
| Staff flu vaccination coverage | 36.46% |
42%
5.5 pts worse
|
Numerator 105 · Denominator 288 |
| Discharge function score | 82.98% |
56.45%
26.5 pts better
|
Numerator 39 · Denominator 47 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 39 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 26.83% |
25.2%
1.6 pts better
|
Numerator 11 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 3.5 · Expected 3.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.2
0.6 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.8 · Expected 2.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 72.2% |
95.7%
23.5 pts worse
|
93.4%
21.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.4% · Q2 70.5% · Q3 74.6% · Q4 68.6% · 4Q avg 72.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
95.0%
3.6 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.2%
1.7 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 4.9% · Q3 3.0% · Q4 1.4% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
5.0%
1.2 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.6% · Q3 3.4% · Q4 4.6% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 8.7% |
4.9%
3.8 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 8.2% · Q3 7.7% · Q4 9.4% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
16.6%
0.4 pts worse
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 15.7% · Q3 14.0% · Q4 14.0% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.4% |
16.7%
2.3 pts better
|
16.7%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 14.6% · Q3 14.0% · Q4 15.2% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.5% |
21.1%
12.6 pts better
|
16.3%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.1% |
17.3%
14.2 pts better
|
14.9%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.2% · Q3 8.0% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
2.3%
1.8 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.8% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
3.0%
2.6 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
25.5%
4.6 pts better
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 16.9% · Q3 19.0% · Q4 18.5% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
5.5%
2.4 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 3.3% · Q3 9.2% · Q4 10.3% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.8% |
86.8%
23 pts worse
|
81.7%
17.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 56.8% · Q2 66.3% · Q3 62.7% · Q4 68.6% · 4Q avg 63.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.3% |
15.0%
7.3 pts worse
|
12.0%
10.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 21.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.3%
1.4 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.0% · Q4 5.6% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.8% |
82.2%
18.4 pts worse
|
79.7%
15.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.6% |
22.7%
1.9 pts worse
|
23.9%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 23.5% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-05 · Fire 2023-12-05
18 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2022-08-25 · Fire 2022-08-25
31 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-20
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-03-20
F · Potential for more than minimal harm
2025-02-20
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-03-20
F · Potential for more than minimal harm
2025-02-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-20
F · Potential for more than minimal harm
2025-02-20
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-03-20
F · Potential for more than minimal harm
2025-02-20
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-03-20
F · Potential for more than minimal harm
2025-02-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-27
F · Potential for more than minimal harm
2025-02-20
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-03-20
F · Potential for more than minimal harm
2025-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-20
F · Potential for more than minimal harm
2025-02-20
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-03-20
F · Potential for more than minimal harm
2025-02-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-20
F · Potential for more than minimal harm
2025-02-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-20
E · Potential for more than minimal harm
2025-02-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-02-20
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-02-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-20
E · Potential for more than minimal harm
2025-02-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-20
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-02-27
F · Potential for more than minimal harm
2023-12-05
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2024-12-02
F · Potential for more than minimal harm
2023-12-05
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-01-14
F · Potential for more than minimal harm
2023-12-05
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-01-11
E · Potential for more than minimal harm
2023-12-05
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-12-26
E · Potential for more than minimal harm
2023-12-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-12-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-12-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-01
C · Minimal harm
2023-12-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-26
C · Minimal harm
2023-12-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-29
C · Minimal harm
2023-12-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-27
F · Potential for more than minimal harm
2022-08-25
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-09-23
F · Potential for more than minimal harm
2022-08-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-23
F · Potential for more than minimal harm
2022-08-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-09-23
F · Potential for more than minimal harm
2022-08-25
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-09-23
F · Potential for more than minimal harm
2022-08-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-21
F · Potential for more than minimal harm
2022-08-25
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-09-23
E · Potential for more than minimal harm
2022-08-25
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-09-23
E · Potential for more than minimal harm
2022-08-25
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-09-23
E · Potential for more than minimal harm
2022-08-25
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-09-23
E · Potential for more than minimal harm
2022-08-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-08-10
E · Potential for more than minimal harm
2022-08-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-25
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2022-09-23
E · Potential for more than minimal harm
2022-08-25
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2022-09-23
E · Potential for more than minimal harm
2022-08-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-23
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2026-01-26
G · Actual harm
2025-11-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-10-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-10-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-10-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-05
J · Immediate jeopardy
2025-07-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-07-16
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-08-06
E · Potential for more than minimal harm
2025-07-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-07-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-05-30
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-30
G · Actual harm
2025-02-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-28
J · Immediate jeopardy
2024-11-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-11-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-06-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-05
J · Immediate jeopardy
2023-12-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-02
F · Potential for more than minimal harm
2023-12-05
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-01-02
E · Potential for more than minimal harm
2023-12-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-02
E · Potential for more than minimal harm
2023-12-05
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-05
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-05
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-02
C · Minimal harm
2023-12-05
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-01-02
E · Potential for more than minimal harm
2023-09-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-15
J · Immediate jeopardy
2023-07-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-15
J · Immediate jeopardy
2023-07-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-03
E · Potential for more than minimal harm
2023-07-12
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-07-12
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-07-12
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-07-12
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-05-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-05-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-01
K · Immediate jeopardy
2022-08-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-23
J · Immediate jeopardy
2022-08-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-09-23
G · Actual harm
2022-08-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-23
G · Actual harm
2022-08-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-23
F · Potential for more than minimal harm
2022-08-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-23
F · Potential for more than minimal harm
2022-08-25
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-09-23
E · Potential for more than minimal harm
2022-08-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-09-23
E · Potential for more than minimal harm
2022-08-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-09-23
E · Potential for more than minimal harm
2022-08-25
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-25
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-25
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-25
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-25
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-25
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-09-23
C · Minimal harm
2022-08-25
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-09-23
Penalties and ownership
What sits behind the stars
$44,532
2025-02-20
Fine
Fine · fine $44,532
Fine
$121,797
2024-11-08
Fine
Fine · fine $121,797
Fine
$15,593
2023-12-05
Fine
Fine · fine $15,593
Fine
$0
2023-12-05
Payment Denial
Payment Denial · denial start 2024-01-03 · 11 days
11 day denial
$89,853
2023-07-12
Fine
Fine · fine $89,853
Fine
Ownership
Commonspirit Health
5% Or Greater Indirect Ownership Interest · Organization
Sylvania Franciscan Health
5% Or Greater Direct Ownership Interest · Organization
Gulock, Michael
W-2 Managing Employee · Individual
Iffland, Alisa
Corporate Officer · Individual
Lipsey, Prentice
Corporate Officer · Individual
Melfi, Mitch
Corporate Director · Individual
Rehmer, Heather
Corporate Officer · Individual
Richardson Mbanu, Terika
Corporate Director · Individual
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