Cycle 1
Health 2025-09-09 · Fire 2025-09-09
24 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Madison, WI
Oak Park Nursing And Rehab Center
1-star overall rating with 1-star inspections with 24 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
718 Jupiter Drive, Madison, WI
(608) 663-8600
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1975-09-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.95
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.21
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.95
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.03
CMS adjusted RN staffing hours
Adjusted total hours
4.57
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,824
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9887
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.95% · Performance 24.10% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.12
Baseline 6.78% · Performance 6.30% · Measure score 5.12 · Achievement 5.12 · Improvement 2.18
Total nurse turnover
4.60
Baseline 47.00% · Performance 44.90% · Measure score 4.60 · Achievement 4.60 · Improvement 0.45
Adjusted total nurse staffing
4.24
Baseline 3.81 hours · Performance 4.28 hours · Measure score 4.24 · Achievement 4.24 · Improvement 1.90
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.73% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 445 · Observed rate 13.93% · Lower 95% interval 10.31% |
| Discharge to community | 52.08% |
50.57%
1.5 pts better
|
No Different than the National Rate · Eligible stays 415 · Observed rate 46.75% · Lower 95% interval 47.06% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 282 · Denominator 282 |
| Falls with major injury | 0.35% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 282 |
| Discharge self-care score | 43.12% |
53.69%
10.6 pts worse
|
Numerator 94 · Denominator 218 |
| Discharge mobility score | 60.09% |
50.94%
9.2 pts better
|
Numerator 131 · Denominator 218 |
| Pressure ulcers or injuries, new or worsened | 2.84% |
2.29%
0.5 pts worse
|
Numerator 8 · Denominator 282 · Adjusted rate 3.96% |
| Healthcare-associated infections requiring hospitalization | 6.3% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 262 · Observed rate 5.34% · Lower 95% interval 4.16% |
| Staff COVID-19 vaccination coverage | 3.21% |
8.2%
5 pts worse
|
Numerator 5 · Denominator 156 |
| Staff flu vaccination coverage | 27.49% |
42%
14.5 pts worse
|
Numerator 47 · Denominator 171 |
| Discharge function score | 58.26% |
56.45%
1.8 pts better
|
Numerator 127 · Denominator 218 |
| Transfer of health information to provider | 96.39% |
95.95%
0.4 pts better
|
Numerator 187 · Denominator 194 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 45 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 43.71% |
25.2%
18.5 pts better
|
Numerator 66 · Denominator 151 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.2
1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
95.7%
4.6 pts worse
|
93.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.7% · Q2 95.2% · Q3 92.7% · Q4 92.9% · 4Q avg 91.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
3.2%
2.6 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
5.0%
1.6 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.0% · Q3 5.7% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
4.9%
4.1 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.3% |
16.6%
2.3 pts better
|
19.6%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 14.7% · Q3 16.1% · Q4 11.8% · 4Q avg 14.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.9% |
16.7%
2.8 pts better
|
16.7%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 12.0% · Q3 16.0% · Q4 14.8% · 4Q avg 13.9% · 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 | 36.9% |
21.1%
15.8 pts worse
|
16.3%
20.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.4% |
17.3%
5.9 pts better
|
14.9%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 17.6% · Q3 9.7% · Q4 9.1% · 4Q avg 11.4% · 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 1.7% · Q2 1.5% · Q3 1.5% · Q4 1.5% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
3.0%
2.4 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.1% |
25.5%
7.6 pts worse
|
19.8%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 29.7% · Q3 41.8% · Q4 34.7% · 4Q avg 33.1% |
| Percentage of long-stay residents with pressure ulcers | 8.4% |
5.5%
2.9 pts worse
|
5.1%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 8.7% · Q3 7.8% · Q4 9.8% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.9% |
86.8%
6.9 pts worse
|
81.7%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 80.9% · Q2 73.8% · Q3 80.8% · Q4 85.1% · 4Q avg 79.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
15.0%
1.3 pts better
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 12.6% · Expected 10.3% · 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 0.8% · Q4 1.5% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.3% |
82.2%
5.1 pts better
|
79.7%
7.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
22.7%
3.2 pts worse
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 23.2% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-16 · Fire 2024-07-16
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2023-04-17 · Fire 2023-04-17
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
16 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-03
E · Potential for more than minimal harm
2025-09-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-08-28
E · Potential for more than minimal harm
2025-09-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-10-02
E · Potential for more than minimal harm
2025-09-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-09-03
E · Potential for more than minimal harm
2025-09-09
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-08-27
D · Potential for more than minimal harm
2025-09-09
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 2025-09-05
D · Potential for more than minimal harm
2025-09-09
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-09-24
F · Potential for more than minimal harm
2024-07-16
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 2024-08-09
F · Potential for more than minimal harm
2024-07-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-07-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-07-16
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 2024-08-09
E · Potential for more than minimal harm
2024-07-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-16
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 2024-08-19
D · Potential for more than minimal harm
2024-07-16
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 2024-08-19
D · Potential for more than minimal harm
2024-07-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Not marked corrected
D · Potential for more than minimal harm
2024-07-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-09
F · Potential for more than minimal harm
2023-04-17
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-05-05
F · Potential for more than minimal harm
2023-04-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-08
F · Potential for more than minimal harm
2023-04-17
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-05-23
F · Potential for more than minimal harm
2023-04-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-05
F · Potential for more than minimal harm
2023-04-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-05
F · Potential for more than minimal harm
2023-04-17
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 2023-05-12
F · Potential for more than minimal harm
2023-04-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-05
E · Potential for more than minimal harm
2023-04-17
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 2023-05-05
E · Potential for more than minimal harm
2023-04-17
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 2023-05-05
E · Potential for more than minimal harm
2023-04-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-04-17
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-04-17
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-17
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-05
Inspection history
Recent health citations
L · Immediate jeopardy
2026-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-09
L · Immediate jeopardy
2026-01-10
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 2026-02-09
D · Potential for more than minimal harm
2026-01-10
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 2026-02-09
D · Potential for more than minimal harm
2025-12-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-12-05
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 2026-01-06
D · Potential for more than minimal harm
2025-12-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-06
J · Immediate jeopardy
2025-09-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-06
G · Actual harm
2025-09-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-06
F · Potential for more than minimal harm
2025-09-09
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 2025-10-06
F · Potential for more than minimal harm
2025-09-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-09-09
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 2025-10-06
E · Potential for more than minimal harm
2025-09-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-09-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-09
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 2025-10-06
D · Potential for more than minimal harm
2025-09-09
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-09
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 2025-10-06
D · Potential for more than minimal harm
2025-09-09
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-10-06
F · Potential for more than minimal harm
2024-07-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-16
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 2024-08-09
D · Potential for more than minimal harm
2024-07-16
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 2024-08-09
D · Potential for more than minimal harm
2024-07-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-16
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 2024-08-09
D · Potential for more than minimal harm
2024-07-16
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 2024-08-16
D · Potential for more than minimal harm
2024-03-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-01-23
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 2024-02-12
D · Potential for more than minimal harm
2024-01-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-12
D · Potential for more than minimal harm
2023-08-31
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 2023-09-28
D · Potential for more than minimal harm
2023-05-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-01
G · Actual harm
2023-04-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-17
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 2023-05-12
E · Potential for more than minimal harm
2023-04-17
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 2023-05-12
E · Potential for more than minimal harm
2023-04-17
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-17
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-05-12
Penalties and ownership
What sits behind the stars
$0
2023-04-17
Payment Denial
Payment Denial · denial start 2023-05-12 · 27 days
27 day denial
Ownership
Frank, Scott
5% Or Greater Direct Ownership Interest · Individual
Sadler, David
5% Or Greater Direct Ownership Interest · Individual
Chase, Theodore
5% Or Greater Direct Ownership Interest · Individual
Chase, Byron
5% Or Greater Direct Ownership Interest · Individual
Halford, Steven
5% Or Greater Direct Ownership Interest · Individual
Bernstein, Gregory
5% Or Greater Direct Ownership Interest · Individual
Frank, Scott
W-2 Managing Employee · Individual
Raab, James
W-2 Managing Employee · Individual
Sadler, Robert
General Partnership Interest · Individual
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3-star overall rating with 2-star inspections with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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