Cycle 1
Health 2025-05-05 · Fire 2025-05-05
17 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Madison, WI
Complete Care at Maple Grove LLC
1-star overall rating with 1-star inspections with $95,303 in total fines with 17 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
3401 Maple Grove Dr., Madison, WI
(608) 845-1000
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
184
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1977-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 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
1.16
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.12
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.94
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.57
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.92
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.23
CMS adjusted RN staffing hours
Adjusted total hours
5.24
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
73%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,679
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.97% · Performance 21.33% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.93
Baseline 6.27% · Performance 7.56% · Measure score 0.93 · Achievement 0.93 · Improvement 0
Total nurse turnover
2.18
Performance 54.76% · Measure score 2.18 · Achievement 2.18 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.69
Baseline 4.65 hours · Performance 4.41 hours · Measure score 4.69 · Achievement 4.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.25% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 156 · Observed rate 8.33% · Lower 95% interval 7.49% |
| Discharge to community | 46.37% |
50.57%
4.2 pts worse
|
No Different than the National Rate · Eligible stays 143 · Observed rate 41.96% · Lower 95% interval 39.46% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 104 · Denominator 104 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 104 |
| Discharge self-care score | 41.67% |
53.69%
12 pts worse
|
Numerator 35 · Denominator 84 |
| Discharge mobility score | 38.1% |
50.94%
12.8 pts worse
|
Numerator 32 · Denominator 84 |
| Pressure ulcers or injuries, new or worsened | 0.96% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 104 · Adjusted rate 1.15% |
| Healthcare-associated infections requiring hospitalization | 7.56% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 7.23% · Lower 95% interval 4.67% |
| Staff COVID-19 vaccination coverage | 1.92% |
8.2%
6.3 pts worse
|
Numerator 3 · Denominator 156 |
| Staff flu vaccination coverage | 78.87% |
42%
36.9 pts better
|
Numerator 153 · Denominator 194 |
| Discharge function score | 52.38% |
56.45%
4.1 pts worse
|
Numerator 44 · Denominator 84 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 51 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 53.49% |
25.2%
28.3 pts better
|
Numerator 23 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.2
0.5 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
95.7%
0.4 pts worse
|
93.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 100.0% · Q3 88.5% · Q4 95.3% · 4Q avg 95.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.9% |
95.0%
1.9 pts better
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.2%
2.4 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 7.7% · Q3 5.7% · Q4 7.1% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
5.0%
3.6 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.1% · Q3 1.2% · Q4 1.2% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
4.9%
0.1 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.4% · Q3 7.7% · Q4 7.6% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
16.6%
2 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 15.3% · Q3 14.7% · Q4 10.4% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.4% |
16.7%
0.3 pts better
|
16.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 25.5% · Q3 14.0% · Q4 9.4% · 4Q avg 16.4% · 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 | 18.4% |
21.1%
2.7 pts better
|
16.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 27.0% · Q3 14.5% · Q4 6.2% · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.3% |
17.3%
3 pts better
|
14.9%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 23.6% · Q3 10.3% · Q4 3.0% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.7% |
2.3%
1.4 pts worse
|
1.0%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.3% · Q3 2.9% · Q4 3.2% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
3.0%
1.6 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.4% · Q3 1.2% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.0% |
25.5%
11.5 pts worse
|
19.8%
17.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.3% · Q2 37.4% · Q3 34.4% · Q4 33.0% · 4Q avg 37.0% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
5.5%
About the same
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 7.0% · Q3 2.5% · Q4 2.9% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.5% |
86.8%
9.3 pts worse
|
81.7%
4.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 91.3% · Q2 84.8% · Q3 60.0% · Q4 69.9% · 4Q avg 77.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.6% |
15.0%
0.4 pts better
|
12.0%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 13.8% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 2.7% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.8% |
82.2%
2.6 pts better
|
79.7%
5.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.1% |
22.7%
3.6 pts better
|
23.9%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 17.5% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-02 · Fire 2024-05-02
34 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2023-02-27 · Fire 2023-02-27
19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-24
F · Potential for more than minimal harm
2025-05-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-06-24
F · Potential for more than minimal harm
2025-05-05
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-06-24
F · Potential for more than minimal harm
2025-05-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-24
F · Potential for more than minimal harm
2025-05-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-24
F · Potential for more than minimal harm
2025-05-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-24
F · Potential for more than minimal harm
2025-05-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-24
E · Potential for more than minimal harm
2025-05-05
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-06-24
E · Potential for more than minimal harm
2025-05-05
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-06-24
E · Potential for more than minimal harm
2025-05-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-24
E · Potential for more than minimal harm
2025-05-05
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-06-24
E · Potential for more than minimal harm
2025-05-05
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-24
F · Potential for more than minimal harm
2024-05-02
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-05-24
F · Potential for more than minimal harm
2024-05-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-05-02
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-05-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-05-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-05-02
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-02
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 2024-05-24
D · Potential for more than minimal harm
2024-05-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-14
F · Potential for more than minimal harm
2023-02-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-02-27
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 2023-04-27
E · Potential for more than minimal harm
2023-02-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-02-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-27
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-27
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-27
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-27
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-04-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-29
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 2025-08-12
G · Actual harm
2025-05-05
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 2025-06-09
F · Potential for more than minimal harm
2025-05-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-09
E · Potential for more than minimal harm
2025-05-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-09
E · Potential for more than minimal harm
2025-05-05
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 2025-06-09
D · Potential for more than minimal harm
2025-05-05
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-05
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-05
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-05
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 2025-06-09
D · Potential for more than minimal harm
2025-05-05
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-05
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-05
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 2025-06-09
D · Potential for more than minimal harm
2025-05-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-05
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-09
G · Actual harm
2025-03-28
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 2025-04-26
D · Potential for more than minimal harm
2025-03-28
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-28
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 2025-04-26
E · Potential for more than minimal harm
2024-11-11
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-11-23
D · Potential for more than minimal harm
2024-11-11
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 2024-11-23
G · Actual harm
2024-10-21
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 2024-11-23
D · Potential for more than minimal harm
2024-10-21
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 2024-11-15
J · Immediate jeopardy
2024-09-12
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 2024-10-10
D · Potential for more than minimal harm
2024-09-12
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 2024-10-10
D · Potential for more than minimal harm
2024-06-27
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 2024-07-19
D · Potential for more than minimal harm
2024-06-27
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-27
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 2024-07-19
D · Potential for more than minimal harm
2024-06-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-27
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-27
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 2024-07-19
D · Potential for more than minimal harm
2024-06-27
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 2024-07-19
F · Potential for more than minimal harm
2024-05-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-05-02
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-05-02
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-05-02
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 2024-05-24
E · Potential for more than minimal harm
2024-05-02
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-02
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 2024-05-24
D · Potential for more than minimal harm
2024-05-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-02
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-02
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-24
C · Minimal harm
2024-05-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-04-10
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 2024-05-08
D · Potential for more than minimal harm
2024-04-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-10
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-10
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 2024-05-08
D · Potential for more than minimal harm
2024-04-10
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 2024-05-08
D · Potential for more than minimal harm
2024-04-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-08
G · Actual harm
2024-01-08
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 2024-02-16
D · Potential for more than minimal harm
2024-01-08
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-01-17
J · Immediate jeopardy
2023-12-04
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 2024-02-16
E · Potential for more than minimal harm
2023-12-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-12-04
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 2023-12-22
E · Potential for more than minimal harm
2023-10-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-10-09
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 2023-10-23
D · Potential for more than minimal harm
2023-10-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-02
G · Actual harm
2023-02-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-27
F · Potential for more than minimal harm
2023-02-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-27
F · Potential for more than minimal harm
2023-02-27
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-03-27
E · Potential for more than minimal harm
2023-02-27
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 2023-03-27
E · Potential for more than minimal harm
2023-02-27
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-03-27
E · Potential for more than minimal harm
2023-02-27
F811 · Nutrition and Dietary Deficiencies
Health
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-27
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-27
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-27
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 2023-03-27
D · Potential for more than minimal harm
2023-02-27
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-27
Penalties and ownership
What sits behind the stars
$34,356
2025-03-28
Fine
Fine · fine $34,356
Fine
$12,048
2024-10-21
Fine
Fine · fine $12,048
Fine
$0
2024-10-21
Payment Denial
Payment Denial · denial start 2024-11-15 · 8 days
8 day denial
$15,642
2024-09-12
Fine
Fine · fine $15,642
Fine
$15,239
2023-12-04
Fine
Fine · fine $15,239
Fine
$18,018
2023-12-04
Fine
Fine · fine $18,018
Fine
$0
2023-12-04
Payment Denial
Payment Denial · denial start 2023-12-30 · 48 days
48 day denial
Ownership
Pc Wcm Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Choles, Diana
Operational/Managerial Control · Individual
Helman, Yosef
Operational/Managerial Control · Individual
Maina, Jennifer
Operational/Managerial Control · Individual
Murphy, Sean
Operational/Managerial Control · Individual
Pc Wcm Topco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Sternbuch, Daniel
Operational/Managerial Control · Individual
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#3
Four Winds Manor
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1-star overall rating with 2-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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