Cycle 1
Health 2025-10-03 · Fire 2024-07-15
33 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Oak Creek, WI
Medical Suites At Oak Creek (The)
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $187,064 in total fines with 33 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
2700 Honadel Boulevard, Oak Creek, WI
(414) 435-2005
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
144
Certified beds
Average residents
127
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ignite Medical Resorts
Operator or chain grouping
Approved since
2020-04-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 3 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.82
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
65%
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
11,881
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.12
Baseline 20.06% · Performance 19.98% · Measure score 3.12 · Achievement 3.12 · Improvement 0
Healthcare-associated infections
1.85
Baseline 5.39% · Performance 7.28% · Measure score 1.85 · Achievement 1.85 · Improvement 0
Total nurse turnover
0.99
Baseline 82.26% · Performance 73.72% · Measure score 0.99 · Achievement 0 · Improvement 0.99
Adjusted total nurse staffing
0
Baseline 3.13 hours · Performance 3.17 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.13% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 391 · Observed rate 14.32% · Lower 95% interval 9.21% |
| Discharge to community | 55.93% |
50.57%
5.4 pts better
|
No Different than the National Rate · Eligible stays 339 · Observed rate 45.43% · Lower 95% interval 49.53% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.92% |
95.27%
3.7 pts better
|
Numerator 183 · Denominator 185 |
| Falls with major injury | 1.62% |
0.77%
0.9 pts worse
|
Numerator 3 · Denominator 185 |
| Discharge self-care score | 29.58% |
53.69%
24.1 pts worse
|
Numerator 42 · Denominator 142 |
| Discharge mobility score | 19.72% |
50.94%
31.2 pts worse
|
Numerator 28 · Denominator 142 |
| Pressure ulcers or injuries, new or worsened | 1.08% |
2.29%
1.2 pts better
|
Numerator 2 · Denominator 185 · Adjusted rate 1.2% |
| Healthcare-associated infections requiring hospitalization | 7.28% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 215 · Observed rate 9.3% · Lower 95% interval 5.12% |
| Staff COVID-19 vaccination coverage | 0.64% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 157 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 30.99% |
56.45%
25.5 pts worse
|
Numerator 44 · Denominator 142 |
| Transfer of health information to provider | 81.58% |
95.95%
14.4 pts worse
|
Numerator 31 · Denominator 38 |
| Transfer of health information to patient | 98.75% |
96.28%
2.5 pts better
|
Numerator 79 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 19.23% |
25.2%
6 pts worse
|
Numerator 15 · Denominator 78 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.6
0.9 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 4.0 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.2
1 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.9 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.1% |
95.7%
5.6 pts worse
|
93.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 88.0% · Q3 87.0% · Q4 91.9% · 4Q avg 90.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 51.7% |
95.0%
43.3 pts worse
|
95.5%
43.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 51.7% |
| 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 7.1% · Q2 6.7% · Q3 3.9% · Q4 4.7% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.5% |
5.0%
3.5 pts worse
|
11.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 11.6% · Q3 9.5% · Q4 7.7% · 4Q avg 8.5% |
| Percentage of long-stay residents who lose too much weight | 12.3% |
4.9%
7.4 pts worse
|
5.4%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 14.5% · Q3 6.7% · Q4 11.3% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.8% |
16.6%
4.8 pts better
|
19.6%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 12.3% · Q3 14.1% · Q4 4.1% · 4Q avg 11.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.9% |
16.7%
11.8 pts better
|
16.7%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.1% · Q3 5.7% · Q4 6.2% · 4Q avg 4.9% · 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 | 23.4% |
21.1%
2.3 pts worse
|
16.3%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 27.1% · Q3 14.9% · Q4 30.2% · 4Q avg 23.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
17.3%
1.5 pts better
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 15.9% · Q3 16.4% · Q4 14.7% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
2.3%
0.8 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.1% · Q3 2.2% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
3.0%
0.8 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.8% · Q3 1.4% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
25.5%
4.7 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.0% · Q2 33.1% · Q3 25.4% · Q4 26.5% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
5.5%
0.2 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 2.2% · Q3 8.0% · Q4 6.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.6% |
86.8%
8.2 pts worse
|
81.7%
3.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 81.5% · Q2 79.5% · Q3 73.3% · Q4 80.8% · 4Q avg 78.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
15.0%
0.8 pts better
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 15.2% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.3%
0.2 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.4% · Q3 1.9% · Q4 1.5% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.8% |
82.2%
17.4 pts worse
|
79.7%
14.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.6% |
22.7%
4.1 pts better
|
23.9%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 20.9% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-15 · Fire 2023-07-27
36 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-07-27 · Fire 2022-03-30
43 health deficiencies
Top issue: Quality of Life and Care (14 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-15
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-08-08
F · Potential for more than minimal harm
2024-07-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-07-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-07-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-07-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-07-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-07-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-07-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-07-15
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-07-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-07-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-11
E · Potential for more than minimal harm
2024-07-15
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-07-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-15
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 2024-08-12
F · Potential for more than minimal harm
2023-07-27
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-08-22
F · Potential for more than minimal harm
2023-07-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-22
F · Potential for more than minimal harm
2023-07-27
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-08-29
F · Potential for more than minimal harm
2023-07-27
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 2023-08-22
F · Potential for more than minimal harm
2023-07-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-07-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-22
C · Minimal harm
2023-07-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-22
C · Minimal harm
2023-07-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-22
F · Potential for more than minimal harm
2022-03-30
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-04-25
F · Potential for more than minimal harm
2022-03-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-04-25
F · Potential for more than minimal harm
2022-03-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-04-25
F · Potential for more than minimal harm
2022-03-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-04-25
F · Potential for more than minimal harm
2022-03-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-04-25
F · Potential for more than minimal harm
2022-03-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-25
E · Potential for more than minimal harm
2022-03-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-04-25
E · Potential for more than minimal harm
2022-03-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-04-25
E · Potential for more than minimal harm
2022-03-30
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-04-25
E · Potential for more than minimal harm
2022-03-30
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-04-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-18
D · Potential for more than minimal harm
2025-12-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-18
D · Potential for more than minimal harm
2025-12-18
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 2026-01-18
G · Actual harm
2025-10-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-11-10
F · Potential for more than minimal harm
2025-10-03
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 2025-11-10
F · Potential for more than minimal harm
2025-10-03
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-11-10
F · Potential for more than minimal harm
2025-10-03
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-11-10
E · Potential for more than minimal harm
2025-10-03
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 2025-11-10
E · Potential for more than minimal harm
2025-10-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-10-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-10-03
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 2025-11-10
D · Potential for more than minimal harm
2025-10-03
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-10-03
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 2025-11-10
D · Potential for more than minimal harm
2025-10-03
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 2025-11-10
D · Potential for more than minimal harm
2025-10-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-10-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-10-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-10-03
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 2025-11-10
D · Potential for more than minimal harm
2025-10-03
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-10-03
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 2025-11-10
D · Potential for more than minimal harm
2025-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-10-03
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-08-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-07-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-04
D · Potential for more than minimal harm
2025-07-08
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 2025-08-04
D · Potential for more than minimal harm
2025-06-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-06-04
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 2025-07-01
E · Potential for more than minimal harm
2025-04-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-04-03
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-04-03
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 2025-04-28
D · Potential for more than minimal harm
2025-04-03
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 2025-04-28
D · Potential for more than minimal harm
2025-04-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-04-03
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-04-28
D · Potential for more than minimal harm
2024-12-04
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 2024-12-19
D · Potential for more than minimal harm
2024-12-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-09-11
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-09-11
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 2024-10-01
D · Potential for more than minimal harm
2024-09-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-01
J · Immediate jeopardy
2024-07-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-12
J · Immediate jeopardy
2024-07-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-01
J · Immediate jeopardy
2024-07-15
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 2024-08-12
F · Potential for more than minimal harm
2024-07-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-07-15
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-07-15
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-07-15
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 2024-08-12
E · Potential for more than minimal harm
2024-07-15
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 2024-08-12
E · Potential for more than minimal harm
2024-07-15
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 2024-08-12
E · Potential for more than minimal harm
2024-07-15
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 2024-08-12
E · Potential for more than minimal harm
2024-07-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-15
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 2024-08-12
D · Potential for more than minimal harm
2024-07-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-15
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 2024-08-12
D · Potential for more than minimal harm
2024-07-15
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 2024-10-01
D · Potential for more than minimal harm
2024-07-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-15
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 2024-08-12
D · Potential for more than minimal harm
2024-07-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-15
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 2024-08-12
D · Potential for more than minimal harm
2024-07-15
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-12
K · Immediate jeopardy
2024-04-17
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-05-02
J · Immediate jeopardy
2024-04-17
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-05-02
E · Potential for more than minimal harm
2024-04-17
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 2024-05-02
D · Potential for more than minimal harm
2024-04-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-04-17
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 2024-05-02
D · Potential for more than minimal harm
2024-04-17
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-04-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-04-17
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 2024-05-02
D · Potential for more than minimal harm
2024-04-17
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 2024-05-02
D · Potential for more than minimal harm
2024-04-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-04-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-02
J · Immediate jeopardy
2023-09-19
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 2023-09-09
G · Actual harm
2023-09-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-09
D · Potential for more than minimal harm
2023-09-19
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 2023-09-09
D · Potential for more than minimal harm
2023-09-19
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 2023-09-09
J · Immediate jeopardy
2023-07-27
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 2023-08-22
E · Potential for more than minimal harm
2023-07-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-27
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 2023-08-22
E · Potential for more than minimal harm
2023-07-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-27
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-27
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-27
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-27
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-27
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 2023-08-22
D · Potential for more than minimal harm
2023-07-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-27
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 2023-08-22
D · Potential for more than minimal harm
2023-07-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-27
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-27
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 2023-08-22
D · Potential for more than minimal harm
2023-07-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-27
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 2023-08-22
D · Potential for more than minimal harm
2023-04-10
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 2023-04-14
J · Immediate jeopardy
2023-03-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-14
G · Actual harm
2023-03-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-23
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 2023-04-14
F · Potential for more than minimal harm
2023-03-23
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-03-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-03-23
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 2023-04-14
E · Potential for more than minimal harm
2023-03-23
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-03-23
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-03-23
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-23
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 2023-04-14
D · Potential for more than minimal harm
2023-03-23
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 2023-04-14
D · Potential for more than minimal harm
2023-03-23
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 2023-04-14
D · Potential for more than minimal harm
2023-03-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-23
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 2023-04-14
D · Potential for more than minimal harm
2023-03-23
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 2023-04-14
D · Potential for more than minimal harm
2023-03-23
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-14
Penalties and ownership
What sits behind the stars
$64,527
2024-07-15
Fine
Fine · fine $64,527
Fine
$0
2024-07-15
Payment Denial
Payment Denial · denial start 2024-08-13 · 49 days
49 day denial
$28,100
2024-04-17
Fine
Fine · fine $28,100
Fine
$94,437
2023-07-27
Fine
Fine · fine $94,437
Fine
$0
2023-07-27
Payment Denial
Payment Denial · denial start 2023-08-25 · 15 days
15 day denial
Ownership
Nearby options
Other facilities in reach
#1
Maple Ridge Health Services
Milwaukee, WI
2-star overall rating with 3-star inspections with $14,433 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Autumn Lake Healthcare At Greenfield
Milwaukee, WI
1-star overall rating with 1-star inspections with abuse icon flag with $176,440 in total fines with 28 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Greendale Park Nursing and Rehab
Greendale, WI
1-star overall rating with 1-star inspections with $271,160 in total fines with 19 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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