Cycle 1
Health 2025-05-01 · Fire 2025-05-01
26 health deficiencies
Top issue: Administration (5 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
West Allis, WI
Maplewood Center
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
8615 W Beloit Rd, West Allis, WI
(414) 607-4100
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
106
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1969-10-01
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
1.03
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.43
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.11
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.47
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.39
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
4.48
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,649
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9891
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.23
Baseline 27.30% · Performance 22.44% · Measure score 4.23 · Achievement 0 · Improvement 4.23
Healthcare-associated infections
3.69
Baseline 5.91% · Performance 6.73% · Measure score 3.69 · Achievement 3.69 · Improvement 0
Total nurse turnover
4.77
Baseline 54.55% · Performance 44.19% · Measure score 4.77 · Achievement 4.77 · Improvement 2.99
Adjusted total nurse staffing
1.48
Baseline 3.05 hours · Performance 3.50 hours · Measure score 1.48 · Achievement 1.48 · Improvement 1.15
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.85% |
10.72%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 172 · Observed rate 18.6% · Lower 95% interval 10.69% |
| Discharge to community | 49.7% |
50.57%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 144 · Observed rate 39.58% · Lower 95% interval 38.39% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 77.55% |
95.27%
17.7 pts worse
|
Numerator 76 · Denominator 98 |
| Falls with major injury | 1.02% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 98 |
| Discharge self-care score | 36.07% |
53.69%
17.6 pts worse
|
Numerator 22 · Denominator 61 |
| Discharge mobility score | 39.34% |
50.94%
11.6 pts worse
|
Numerator 24 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 2.04% |
2.29%
0.2 pts better
|
Numerator 2 · Denominator 98 · Adjusted rate 1.7% |
| Healthcare-associated infections requiring hospitalization | 6.73% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 6% · Lower 95% interval 4.1% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 90.48% |
42%
48.5 pts better
|
Numerator 190 · Denominator 210 |
| Discharge function score | 40.98% |
56.45%
15.5 pts worse
|
Numerator 25 · Denominator 61 |
| Transfer of health information to provider | 81.4% |
95.95%
14.5 pts worse
|
Numerator 35 · Denominator 43 |
| Transfer of health information to patient | 91.3% |
96.28%
5 pts worse
|
Numerator 21 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 38% |
25.2%
12.8 pts better
|
Numerator 19 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.5 |
1.6
1.9 pts worse
|
1.9
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 4.6 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.2
0.8 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.5 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
95.7%
0.7 pts better
|
93.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.4% · Q2 95.4% · Q3 97.8% · Q4 100.0% · 4Q avg 96.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
95.0%
4 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
3.2%
3.2 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 8.0% · Q3 7.7% · Q4 4.5% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
5.0%
4.7 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
4.9%
1.4 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.8% · Q3 6.4% · Q4 6.8% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.1% |
16.6%
3.5 pts worse
|
19.6%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 18.7% · Q3 21.0% · Q4 19.7% · 4Q avg 20.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
16.7%
7 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 7.8% · Q3 9.4% · Q4 14.5% · 4Q avg 9.7% · 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 | 22.0% |
21.1%
0.9 pts worse
|
16.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.5% |
17.3%
4.2 pts worse
|
14.9%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 31.2% · Q3 11.5% · Q4 19.7% · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
2.3%
0.5 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.2% · Q3 2.4% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.8% |
3.0%
5.8 pts worse
|
1.7%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 8.1% · Q3 8.0% · Q4 2.3% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.7% |
25.5%
9.8 pts better
|
19.8%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 27.5% · Q3 9.8% · Q4 13.3% · 4Q avg 15.7% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
5.5%
2.3 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 5.8% · Q3 9.8% · Q4 9.2% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.4% |
86.8%
2.6 pts better
|
81.7%
7.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 76.1% · Q2 85.9% · Q3 96.2% · Q4 98.6% · 4Q avg 89.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
15.0%
1.9 pts better
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 14.7% · Expected 12.6% · 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 2.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.9% |
82.2%
11.7 pts better
|
79.7%
14.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
22.7%
2.5 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 28.7% · Expected 27.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-04 · Fire 2024-04-04
28 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2022-12-28 · Fire 2022-12-28
24 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-01
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-05-29
F · Potential for more than minimal harm
2025-05-01
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-05-29
F · Potential for more than minimal harm
2025-05-01
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-04-25
F · Potential for more than minimal harm
2025-05-01
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-05-22
F · Potential for more than minimal harm
2025-05-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-05-01
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 2025-05-30
E · Potential for more than minimal harm
2025-05-01
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-04-24
E · Potential for more than minimal harm
2025-05-01
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-05-22
E · Potential for more than minimal harm
2025-05-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-24
E · Potential for more than minimal harm
2025-05-01
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-05-01
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-05-01
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-05-01
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-01
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-05-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-23
C · Minimal harm
2025-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-24
F · Potential for more than minimal harm
2024-04-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-23
F · Potential for more than minimal harm
2024-04-04
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-04-22
F · Potential for more than minimal harm
2024-04-04
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-04-22
F · Potential for more than minimal harm
2024-04-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-22
F · Potential for more than minimal harm
2024-04-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-02
E · Potential for more than minimal harm
2024-04-04
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 2024-04-22
E · Potential for more than minimal harm
2024-04-04
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 2024-04-22
E · Potential for more than minimal harm
2024-04-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-22
E · Potential for more than minimal harm
2024-04-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-22
E · Potential for more than minimal harm
2024-04-04
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-04-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-22
F · Potential for more than minimal harm
2022-12-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-20
F · Potential for more than minimal harm
2022-12-28
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-12-28
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-12-28
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-12-28
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-12-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-12-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-12-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-12-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-12-28
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-28
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 2023-01-20
Inspection history
Recent health citations
C · Minimal harm
2025-07-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-08-06
K · Immediate jeopardy
2025-05-01
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 2025-05-30
G · Actual harm
2025-05-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-05-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-05-01
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-05-01
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-05-01
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-05-01
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-05-01
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-05-01
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 2025-05-30
F · Potential for more than minimal harm
2025-05-01
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-01
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-01
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 2025-05-30
E · Potential for more than minimal harm
2025-05-01
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 2025-05-30
E · Potential for more than minimal harm
2025-05-01
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-01
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 2025-05-30
E · Potential for more than minimal harm
2025-05-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-01
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 2025-05-30
D · Potential for more than minimal harm
2025-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-01
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-01
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 2025-05-30
D · Potential for more than minimal harm
2025-05-01
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 2025-05-30
D · Potential for more than minimal harm
2025-05-01
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 2025-05-30
D · Potential for more than minimal harm
2025-05-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-01
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-30
K · Immediate jeopardy
2025-02-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-05
J · Immediate jeopardy
2025-02-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-13
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-13
F560 · Resident Rights Deficiencies
Health
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-13
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-13
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 2025-03-05
D · Potential for more than minimal harm
2025-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-05
D · Potential for more than minimal harm
2024-11-12
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 2024-12-10
D · Potential for more than minimal harm
2024-11-12
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 2024-12-10
D · Potential for more than minimal harm
2024-11-12
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 2024-12-10
D · Potential for more than minimal harm
2024-11-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-12
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 2024-12-10
D · Potential for more than minimal harm
2024-11-12
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 2024-12-10
D · Potential for more than minimal harm
2024-11-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-05-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-29
D · Potential for more than minimal harm
2024-05-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-06-29
D · Potential for more than minimal harm
2024-05-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-29
F · Potential for more than minimal harm
2024-04-04
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 2024-05-04
F · Potential for more than minimal harm
2024-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-04
E · Potential for more than minimal harm
2024-04-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-04
D · Potential for more than minimal harm
2024-04-04
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 2024-05-04
D · Potential for more than minimal harm
2024-04-04
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 2024-05-04
D · Potential for more than minimal harm
2024-04-04
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 2024-05-04
D · Potential for more than minimal harm
2024-04-04
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-04
D · Potential for more than minimal harm
2024-04-04
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 2024-05-04
J · Immediate jeopardy
2024-01-13
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 2024-02-09
D · Potential for more than minimal harm
2024-01-13
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 2024-02-09
D · Potential for more than minimal harm
2024-01-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-13
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 2024-02-09
G · Actual harm
2023-10-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-10
G · Actual harm
2023-10-12
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 2023-11-10
D · Potential for more than minimal harm
2023-10-12
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 2023-11-10
D · Potential for more than minimal harm
2023-10-12
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 2023-11-10
D · Potential for more than minimal harm
2023-10-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-12
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 2023-11-10
J · Immediate jeopardy
2022-12-28
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 2023-03-07
G · Actual harm
2022-12-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-07
G · Actual harm
2022-12-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-28
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 2023-02-07
E · Potential for more than minimal harm
2022-12-28
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 2023-02-07
E · Potential for more than minimal harm
2022-12-28
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 2023-02-07
E · Potential for more than minimal harm
2022-12-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-03-07
D · Potential for more than minimal harm
2022-12-28
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 2023-02-07
D · Potential for more than minimal harm
2022-12-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-02-07
D · Potential for more than minimal harm
2022-12-28
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 2023-02-07
D · Potential for more than minimal harm
2022-12-28
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 2023-02-07
D · Potential for more than minimal harm
2022-12-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-02-07
C · Minimal harm
2022-12-28
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-02-07
Penalties and ownership
What sits behind the stars
$145,850
2025-05-01
Fine
Fine · fine $145,850
Fine
$298,680
2025-02-13
Fine
Fine · fine $298,680
Fine
$0
2025-02-13
Payment Denial
Payment Denial · denial start 2025-02-28 · 5 days
5 day denial
$14,053
2024-01-13
Fine
Fine · fine $14,053
Fine
$49,485
2023-10-12
Fine
Fine · fine $49,485
Fine
Ownership
Affeldt, David
Operational/Managerial Control · Individual
Affeldt, David
Corporate Officer · Individual
Kellar, Richard
Corporate Director · Individual
New Horizon Foods, LLC
Operational/Managerial Control · Organization
Rabe, Susan
Corporate Director · Individual
Rehab Solutions Group, LLC
Operational/Managerial Control · Organization
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#3
Aria At Mitchell Manor
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