Cycle 1
Health 2024-10-28 · Fire 2024-10-28
18 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Middleton, WI
Middleton Village Nursing And Rehab
1-star overall rating with 1-star inspections with $84,573 in total fines with 18 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
6201 Elmwood Ave, Middleton, WI
(608) 831-8300
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
97
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Shlomo Hoffman
Operator or chain grouping
Approved since
1982-12-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 2 overall / 3 health / 3 staffing / 3 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
0.58
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.70
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.39
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
0.31
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.67
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,294
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.88
Baseline 19.13% · Performance 20.56% · Measure score 1.88 · Achievement 1.88 · Improvement 0
Healthcare-associated infections
0.83
Baseline 6.56% · Performance 7.58% · Measure score 0.83 · Achievement 0.83 · Improvement 0
Total nurse turnover
0
Performance 64.44% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.02
Baseline 3.02 hours · Performance 3.16 hours · Measure score 0.02 · Achievement 0 · Improvement 0.02
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.9% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 7.92% · Lower 95% interval 7.08% |
| Discharge to community | 36.05% |
50.57%
14.5 pts worse
|
Worse than the National Rate · Eligible stays 130 · Observed rate 28.46% · Lower 95% interval 26.29% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 92.75% |
95.27%
2.5 pts worse
|
Numerator 64 · Denominator 69 |
| Falls with major injury | 1.45% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 69 |
| Discharge self-care score | 54.76% |
53.69%
1.1 pts better
|
Numerator 23 · Denominator 42 |
| Discharge mobility score | 38.1% |
50.94%
12.8 pts worse
|
Numerator 16 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 1.45% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 69 · Adjusted rate 1.23% |
| Healthcare-associated infections requiring hospitalization | 7.59% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 90 · Observed rate 8.89% · Lower 95% interval 4.75% |
| Staff COVID-19 vaccination coverage | 16% |
8.2%
7.8 pts better
|
Numerator 12 · Denominator 75 |
| Staff flu vaccination coverage | 29.11% |
42%
12.9 pts worse
|
Numerator 23 · Denominator 79 |
| Discharge function score | 47.62% |
56.45%
8.8 pts worse
|
Numerator 20 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 37 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 76% |
25.2%
50.8 pts better
|
Numerator 19 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.1 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.2
0.1 pts better
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.5 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.9% |
95.0%
4.1 pts worse
|
95.5%
4.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.2%
2.2 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.9% · Q3 6.2% · Q4 5.0% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 70.2% |
5.0%
65.2 pts worse
|
11.4%
58.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.7% · Q2 76.2% · Q3 83.3% · Q4 69.5% · 4Q avg 70.2% |
| 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 6.8% · Q2 10.0% · Q3 5.3% · Q4 2.1% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
16.6%
3.9 pts worse
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 22.6% · Q3 20.7% · Q4 17.0% · 4Q avg 20.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
16.7%
1.1 pts better
|
16.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 18.6% · Q3 9.8% · Q4 11.6% · 4Q avg 15.6% · 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 | 6.0% |
21.1%
15.1 pts better
|
16.3%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 7.7% · Q3 0.0% · Q4 4.1% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.8% |
17.3%
8.5 pts better
|
14.9%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 11.7% · Q3 5.3% · Q4 9.8% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.7% |
2.3%
0.4 pts worse
|
1.0%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 3.7% · Q4 2.2% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
3.0%
1.4 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 1.6% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.4% |
25.5%
2.1 pts better
|
19.8%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 29.0% · Q3 16.4% · Q4 16.1% · 4Q avg 23.4% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
5.5%
1.3 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.2% · Q3 3.1% · Q4 1.6% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
86.8%
12.9 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.4% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.3% |
15.0%
1.7 pts better
|
12.0%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 14.1% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.3%
1.7 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.4% · Q4 6.7% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
82.2%
9.5 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
22.7%
2.6 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 26.6% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
32 health deficiencies
Top issue: Quality of Life and Care (13 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2022-08-18 · Fire 2022-08-18
23 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-10-28
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-10-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-10-28
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-10-28
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-10-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-10-28
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-10-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-10-28
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-10-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-10-28
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 2024-11-19
D · Potential for more than minimal harm
2024-10-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-19
F · Potential for more than minimal harm
2023-10-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-12
E · Potential for more than minimal harm
2023-10-26
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-26
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 2023-12-04
E · Potential for more than minimal harm
2023-10-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-21
E · Potential for more than minimal harm
2023-10-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-10-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-26
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 2023-11-17
D · Potential for more than minimal harm
2023-10-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-17
F · Potential for more than minimal harm
2022-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-24
E · Potential for more than minimal harm
2022-08-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-08-29
E · Potential for more than minimal harm
2022-08-18
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-08-24
E · Potential for more than minimal harm
2022-08-18
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-18
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 2022-09-02
D · Potential for more than minimal harm
2022-08-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-05
D · Potential for more than minimal harm
2022-08-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-08-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-08
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 2025-10-09
D · Potential for more than minimal harm
2025-10-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-09
F · Potential for more than minimal harm
2025-05-07
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 2025-05-22
E · Potential for more than minimal harm
2025-05-07
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 2025-07-10
D · Potential for more than minimal harm
2025-05-07
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 2025-05-22
D · Potential for more than minimal harm
2025-05-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-05-07
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 2025-05-22
D · Potential for more than minimal harm
2025-05-07
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 2025-05-22
G · Actual harm
2024-10-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-19
G · Actual harm
2024-10-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-22
G · Actual harm
2024-10-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-19
F · Potential for more than minimal harm
2024-10-28
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 2024-11-19
F · Potential for more than minimal harm
2024-10-28
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-10-28
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-28
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 2024-11-19
D · Potential for more than minimal harm
2024-10-28
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 2024-11-19
D · Potential for more than minimal harm
2024-10-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-10-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-05-24
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-05-24
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-05-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-05-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-05-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-05-16
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 2024-06-04
D · Potential for more than minimal harm
2024-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-04-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-04-24
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 2024-05-16
J · Immediate jeopardy
2024-04-18
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 2024-02-25
D · Potential for more than minimal harm
2024-04-18
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 2024-05-10
D · Potential for more than minimal harm
2024-04-18
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 2024-05-10
D · Potential for more than minimal harm
2024-04-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-02-12
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 2024-02-19
D · Potential for more than minimal harm
2024-02-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-23
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 2024-02-08
F · Potential for more than minimal harm
2023-10-26
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 2023-11-17
F · Potential for more than minimal harm
2023-10-26
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-26
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 2023-11-17
E · Potential for more than minimal harm
2023-10-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
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 2023-11-17
D · Potential for more than minimal harm
2023-10-26
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 2023-11-17
D · Potential for more than minimal harm
2023-10-26
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 2023-11-17
D · Potential for more than minimal harm
2023-10-26
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
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 2023-11-17
D · Potential for more than minimal harm
2023-10-26
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 2023-11-17
D · Potential for more than minimal harm
2023-10-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
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 2023-11-17
D · Potential for more than minimal harm
2023-10-26
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-17
J · Immediate jeopardy
2023-06-21
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 2023-02-03
F · Potential for more than minimal harm
2023-06-21
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 2023-07-12
E · Potential for more than minimal harm
2023-06-21
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-07-12
E · Potential for more than minimal harm
2023-06-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-12
E · Potential for more than minimal harm
2023-06-21
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 2023-07-12
D · Potential for more than minimal harm
2023-06-21
F555 · Resident Rights Deficiencies
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-06-21
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 2023-07-12
D · Potential for more than minimal harm
2023-06-21
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 2023-07-12
D · Potential for more than minimal harm
2023-06-21
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-06-21
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 2023-07-12
D · Potential for more than minimal harm
2023-06-21
F774 · Administration Deficiencies
Health
Help the resident with transportation to and from laboratory services outside of the facility.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-06-21
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-07-12
G · Actual harm
2022-08-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-13
G · Actual harm
2022-08-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-13
F · Potential for more than minimal harm
2022-08-18
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 2022-09-13
D · Potential for more than minimal harm
2022-08-18
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 2022-09-13
D · Potential for more than minimal harm
2022-08-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-09-13
D · Potential for more than minimal harm
2022-08-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-09-13
D · Potential for more than minimal harm
2022-08-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-09-13
D · Potential for more than minimal harm
2022-08-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-13
Penalties and ownership
What sits behind the stars
$55,734
2024-10-28
Fine
Fine · fine $55,734
Fine
$0
2024-10-28
Payment Denial
Payment Denial · denial start 2024-11-26 · 10 days
10 day denial
$12,038
2024-04-18
Fine
Fine · fine $12,038
Fine
$16,801
2023-06-21
Fine
Fine · fine $16,801
Fine
Ownership
Jeidel, Jacob
5% Or Greater Direct Ownership Interest · Individual
Hoffman, Shlomo
5% Or Greater Direct Ownership Interest · Individual
Shkop, Benjamin
5% Or Greater Direct Ownership Interest · Individual
Jacobson, Eric
W-2 Managing Employee · Individual
Jeidel, Jacob
Corporate Officer · Individual
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