Cycle 1
Health 2025-01-21 · Fire 2025-01-21
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
New Berlin, WI
Lindengrove New Berlin
1-star overall rating with 1-star inspections with $125,115 in total fines with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
13755 W Fieldpointe Dr, New Berlin, WI
(262) 796-3660
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
79
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.67
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.48
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.43
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.41
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
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.88
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,875
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.38
Baseline 18.74% · Performance 20.79% · Measure score 1.38 · Achievement 1.38 · Improvement 0
Healthcare-associated infections
1.19
Baseline 5.70% · Performance 7.48% · Measure score 1.19 · Achievement 1.19 · Improvement 0
Total nurse turnover
3.49
Baseline 45.83% · Performance 49.41% · Measure score 3.49 · Achievement 3.49 · Improvement 0
Adjusted total nurse staffing
1.45
Baseline 3.54 hours · Performance 3.49 hours · Measure score 1.45 · Achievement 1.45 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.99% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 162 · Observed rate 15.43% · Lower 95% interval 9.69% |
| Discharge to community | 49.84% |
50.57%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 165 · Observed rate 43.03% · Lower 95% interval 40.91% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.8% |
95.27%
3.5 pts better
|
Numerator 82 · Denominator 83 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 83 |
| Discharge self-care score | 53.13% |
53.69%
0.6 pts worse
|
Numerator 34 · Denominator 64 |
| Discharge mobility score | 42.19% |
50.94%
8.8 pts worse
|
Numerator 27 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 2.41% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 83 · Adjusted rate 1.95% |
| Healthcare-associated infections requiring hospitalization | 7.48% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 7.55% · Lower 95% interval 4.43% |
| Staff COVID-19 vaccination coverage | 8.53% |
8.2%
0.3 pts better
|
Numerator 11 · Denominator 129 |
| Staff flu vaccination coverage | 49.35% |
42%
7.4 pts better
|
Numerator 76 · Denominator 154 |
| Discharge function score | 51.56% |
56.45%
4.9 pts worse
|
Numerator 33 · Denominator 64 |
| 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 | 97.96% |
96.28%
1.7 pts better
|
Numerator 48 · Denominator 49 |
| Resident COVID-19 vaccinations up to date | 9.09% |
25.2%
16.1 pts worse
|
Numerator 3 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.6
0.5 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.2
0.9 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
95.7%
0.6 pts worse
|
93.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.4% · Q2 92.6% · Q3 97.0% · Q4 98.4% · 4Q avg 95.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
95.0%
2.4 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.2%
0.2 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.9% · Q3 3.0% · Q4 4.8% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 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 who lose too much weight | 2.1% |
4.9%
2.8 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 3.9% · Q4 2.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.8% |
16.6%
0.8 pts better
|
19.6%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 18.4% · Q3 13.7% · Q4 15.7% · 4Q avg 15.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
16.7%
4 pts better
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 10.3% · Q3 14.6% · Q4 15.2% · 4Q avg 12.7% · 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 | 22.8% |
21.1%
1.7 pts worse
|
16.3%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.8% |
17.3%
0.5 pts better
|
14.9%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 14.9% · Q3 12.8% · Q4 25.0% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
2.3%
1.1 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.3% · Q4 2.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
3.0%
0.8 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.0% · Q3 4.5% · Q4 4.8% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.8% |
25.5%
6.3 pts worse
|
19.8%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.8% · Q2 36.5% · Q3 23.3% · Q4 29.5% · 4Q avg 31.8% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
5.5%
0.7 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.1% · Q3 7.6% · Q4 5.5% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.4% |
86.8%
3.4 pts worse
|
81.7%
1.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 78.5% · Q2 81.0% · Q3 86.7% · Q4 88.3% · 4Q avg 83.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
15.0%
4.7 pts better
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 9.9% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 71.1% |
82.2%
11.1 pts worse
|
79.7%
8.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.4% |
22.7%
6.3 pts better
|
23.9%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 15.5% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-07 · Fire 2023-11-07
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-08-10 · Fire 2022-08-10
27 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-21
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-01-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-01-22
E · Potential for more than minimal harm
2025-01-21
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-14
F · Potential for more than minimal harm
2023-11-07
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-03-21
E · Potential for more than minimal harm
2023-11-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-07
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-12-06
E · Potential for more than minimal harm
2022-08-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-08-15
Inspection history
Recent health citations
G · Actual harm
2025-09-08
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 2025-10-03
D · Potential for more than minimal harm
2025-09-08
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 2025-10-03
D · Potential for more than minimal harm
2025-09-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-03
G · Actual harm
2025-06-26
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 2025-07-25
D · Potential for more than minimal harm
2025-06-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-25
G · Actual harm
2025-01-21
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 2025-03-05
F · Potential for more than minimal harm
2025-01-21
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 2025-03-04
F · Potential for more than minimal harm
2025-01-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-01-21
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 2025-03-04
D · Potential for more than minimal harm
2025-01-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-21
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 2025-03-04
D · Potential for more than minimal harm
2025-01-21
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-21
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 2025-03-04
D · Potential for more than minimal harm
2024-11-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-14
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 2024-12-13
D · Potential for more than minimal harm
2024-11-14
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 2024-12-13
F · Potential for more than minimal harm
2023-11-07
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 2023-12-07
D · Potential for more than minimal harm
2023-11-07
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 2023-12-07
D · Potential for more than minimal harm
2023-11-07
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-11-07
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 2023-12-07
D · Potential for more than minimal harm
2023-11-07
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 2023-12-07
D · Potential for more than minimal harm
2023-11-07
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 2023-12-07
K · Immediate jeopardy
2023-05-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-21
J · Immediate jeopardy
2023-05-23
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 2023-06-21
D · Potential for more than minimal harm
2023-05-23
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-23
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 2023-06-21
D · Potential for more than minimal harm
2023-05-23
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 2023-06-21
D · Potential for more than minimal harm
2023-05-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-23
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-23
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 2023-06-21
D · Potential for more than minimal harm
2023-05-23
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 2023-06-21
D · Potential for more than minimal harm
2023-05-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-23
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-23
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-21
G · Actual harm
2022-08-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-09-06
E · Potential for more than minimal harm
2022-08-10
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 2022-09-08
E · Potential for more than minimal harm
2022-08-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-10
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 2022-09-02
D · Potential for more than minimal harm
2022-08-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-09-08
D · Potential for more than minimal harm
2022-08-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-08
D · Potential for more than minimal harm
2022-08-10
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 2022-09-06
D · Potential for more than minimal harm
2022-08-10
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 2022-09-07
D · Potential for more than minimal harm
2022-08-10
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 2022-09-08
Penalties and ownership
What sits behind the stars
$44,021
2025-01-21
Fine
Fine · fine $44,021
Fine
$0
2025-01-21
Payment Denial
Payment Denial · denial start 2025-02-21 · 12 days
12 day denial
$81,094
2023-05-23
Fine
Fine · fine $81,094
Fine
Ownership
The Hills At Cortland Ridge, Inc.
5% Or Greater Direct Ownership Interest · Organization
Chwala, Nicole
Operational/Managerial Control · Individual
Chwala, Nicole
Corporate Director · Individual
Illuminus Inc
Operational/Managerial Control · Organization
Libby, Michael
Operational/Managerial Control · Individual
Libby, Michael
Corporate Director · Individual
Mauthe, Matthew
Operational/Managerial Control · Individual
Mauthe, Matthew
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Clement Manor Health Care Center
Greenfield, WI
5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
#2
Maplewood Center
West Allis, WI
1-star overall rating with 1-star inspections with $508,068 in total fines with 26 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#3
Resolve At West Allis Respiratory And Rehab
West Allis, WI
1-star overall rating with 1-star inspections with $341,867 in total fines with 23 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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