Bradley Estates Nursing And Rehab LLC
Nursing home · 6735 W BRADLEY RD, Milwaukee, WI 53223 · Milwaukee County
Prices
No published price is available. Ask the facility directly.
Facility
- Type
- Nursing home · TITLE 18 SNF TITLE 19 NF
- Capacity
- 198
- State license
- 2684
- Medicare CCN
- 525325
- Licensed entity
- BRADLEY ESTATES NURSING AND REHAB LLC
- Chain
- SHLOMO HOFFMAN
- Ownership
- For profit - Corporation
- Phone
- (414) 354-3300
- Nurse staffing
- 3.83 hours per resident per day; 70.1% nursing staff turnover
- Medicare ratings
- Inspections 1★ · Staffing 2★ · Quality 2★
- CMS status
- SFF Candidate
- CMS abuse flag
- Cited for abuse (CMS marks this facility with its abuse icon)
- Official record
- Wisconsin DQA Provider Search
- Official record
- Medicare Care Compare
Penalties
- Jan 7, 2025 — Payment Denial · payment denial 1 days
- Jan 7, 2025 — Fine ($79,372)
- Jul 1, 2024 — Fine ($167,635)
- Jul 1, 2024 — Payment Denial · payment denial 117 days
- Jan 17, 2024 — Payment Denial · payment denial 49 days
- Jan 17, 2024 — Fine ($41,266)
- Jan 17, 2024 — Fine ($17,101)
Inspection findings
-
Dec 30, 2025 Health · 4 findings
-
Not serious
Scope/severity D
Complaint
F0565 Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected Jan 28, 2026 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0584 Resident Rights Deficiencies
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 Jan 28, 2026 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected Jan 28, 2026 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Corrected Jan 28, 2026 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
Sep 17, 2025 Fire Safety · 24 findings
-
Not serious
Scope/severity F
E0039 Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Corrected Oct 15, 2025 · CMS fire safety
-
Not serious
Scope/severity D
F0551 Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
Corrected Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0552 Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0582 Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0585 Resident Rights Deficiencies
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 Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity E
F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0640 Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity E
F0641 Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Corrected Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0644 Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0645 Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0677 Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0686 Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0689 Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0757 Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity E
F0761 Pharmacy Service Deficiencies
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 Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity E
F0880 Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Corrected Oct 16, 2025 · CMS health inspection
-
Not serious
Scope/severity E
K0222 Egress Deficiencies
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 Oct 3, 2025 · CMS fire safety
-
Not serious
Scope/severity E
K0321 Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected Oct 3, 2025 · CMS fire safety
-
Not serious
Scope/severity E
K0353 Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Corrected Oct 2, 2025 · CMS fire safety
-
Not serious
Scope/severity D
K0355 Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected Oct 3, 2025 · CMS fire safety
-
Not serious
Scope/severity E
K0511 Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Corrected Oct 10, 2025 · CMS fire safety
-
Not serious
Scope/severity D
K0541 Services Deficiencies
Install properly constructed and protected linen or trash chutes.
Corrected Mar 20, 2026 · CMS fire safety
-
Not serious
Scope/severity E
K0753 Miscellaneous Deficiencies
Have restrictions on the use of highly flammable decorations.
Corrected Oct 10, 2025 · CMS fire safety
-
Not serious
Scope/severity D
K0920 Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Corrected Oct 10, 2025 · CMS fire safety
-
Not serious
Scope/severity F
-
Aug 20, 2025 Health · 3 findings
-
Not serious
Scope/severity D
Complaint
F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected Sep 14, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected Sep 14, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Corrected Sep 14, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
Jul 11, 2025 Health · 3 findings
-
Not serious
Scope/severity E
Complaint
F0584 Resident Rights Deficiencies
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 Aug 8, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Corrected Aug 8, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0689 Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Aug 8, 2025 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
-
Jun 10, 2025 Health · 4 findings
-
Not serious
Scope/severity E
Complaint
F0565 Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected Jul 4, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0755 Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected Jul 4, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0761 Pharmacy Service Deficiencies
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 Jul 4, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0880 Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Corrected Jul 4, 2025 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
-
Apr 1, 2025 Health · 8 findings
-
Not serious
Scope/severity D
Complaint
F0580 Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected Apr 10, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0677 Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Apr 10, 2025 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0755 Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected Apr 10, 2025 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0761 Pharmacy Service Deficiencies
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 Apr 10, 2025 · CMS health inspection
-
Not serious
Scope/severity F
Complaint
F0801 Nutrition and Dietary Deficiencies
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected Apr 10, 2025 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0803 Nutrition and Dietary Deficiencies
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 Apr 10, 2025 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0812 Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected Apr 10, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0880 Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Corrected Apr 10, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
Feb 6, 2025 Health · 4 findings
-
Not serious
Scope/severity D
Complaint
F0580 Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected Feb 7, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0625 Resident Rights Deficiencies
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 Feb 7, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0626 Resident Rights Deficiencies
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected Feb 7, 2025 · CMS health inspection
-
Serious
Scope/severity K
Complaint
F0689 Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Feb 7, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
Jan 7, 2025 Health · 4 findings
-
Not serious
Scope/severity D
Complaint
F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected Jan 21, 2025 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected Jan 21, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0689 Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Feb 7, 2025 · CMS health inspection
-
Serious
Scope/severity G
Complaint
F0690 Quality of Life and Care Deficiencies
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 Feb 4, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
Oct 28, 2024 Health · 3 findings
-
Not serious
Scope/severity D
Complaint
F0622 Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected Oct 29, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0685 Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Corrected Oct 31, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0880 Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Corrected Nov 19, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
Sep 19, 2024 Health · 10 findings
-
Not serious
Scope/severity D
Complaint
F0553 Resident Rights Deficiencies
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected Oct 14, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0580 Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected Oct 14, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0585 Resident Rights Deficiencies
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 Oct 17, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected Oct 14, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Corrected Oct 14, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0657 Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected Dec 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0692 Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Corrected Oct 16, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0758 Pharmacy Service Deficiencies
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 Oct 14, 2024 · CMS health inspection
-
Serious
Scope/severity G
Complaint
F0760 Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Corrected Dec 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0917 Environmental Deficiencies
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
Corrected Oct 17, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
Jul 1, 2024 Fire Safety · 33 findings
-
Not serious
Scope/severity F
E0020 Emergency Preparedness Deficiencies
Establish policies and procedures including evacuation.
Corrected Jul 17, 2024 · CMS fire safety
-
Not serious
Scope/severity D
Complaint
F0602 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity E
F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0622 Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0623 Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0625 Resident Rights Deficiencies
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 Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity E
F0645 Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity D
F0656 Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0657 Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity D
F0677 Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0684 Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Jul 17, 2024 · CMS health inspection
-
Serious
Scope/severity G
F0686 Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Dec 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
F0700 Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected Jul 17, 2024 · CMS health inspection
-
Serious
Scope/severity J
Complaint
F0745 Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity D
F0757 Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity D
F0849 Administration Deficiencies
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 Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity F
F0880 Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity F
F0908 Environmental Deficiencies
Keep all essential equipment working safely.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity F
F0944 Administration Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity F
F0946 Administration Deficiencies
Provide training in compliance and ethics.
Corrected Jul 17, 2024 · CMS health inspection
-
Not serious
Scope/severity E
K0211 Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected Jul 17, 2024 · CMS fire safety
-
Not serious
Scope/severity D
K0321 Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected Jul 17, 2024 · CMS fire safety
-
Not serious
Scope/severity D
K0324 Smoke Deficiencies
Provide properly protected cooking facilities.
Corrected Feb 4, 2025 · CMS fire safety
-
Not serious
Scope/severity E
K0347 Smoke Deficiencies
Properly provide smoke detection systems in areas open to corridors.
Corrected Jul 17, 2024 · CMS fire safety
-
Not serious
Scope/severity D
K0353 Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Corrected Jul 17, 2024 · CMS fire safety
-
Not serious
Scope/severity F
K0354 Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected Jul 17, 2024 · CMS fire safety
-
Not serious
Scope/severity E
K0374 Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected Jul 17, 2024 · CMS fire safety
-
Not serious
Scope/severity E
K0511 Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Corrected Jul 17, 2024 · CMS fire safety
-
Not serious
Scope/severity F
K0711 Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Corrected Jul 17, 2024 · CMS fire safety
-
Not serious
Scope/severity D
K0741 Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected Jul 17, 2024 · CMS fire safety
-
Not serious
Scope/severity D
K0920 Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Corrected Jul 17, 2024 · CMS fire safety
-
Not serious
Scope/severity F
-
Mar 7, 2024 Health · 20 findings
-
Not serious
Scope/severity D
Complaint
F0552 Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0580 Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0585 Resident Rights Deficiencies
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 Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0661 Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0677 Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Apr 5, 2024 · CMS health inspection
-
Serious
Scope/severity G
Complaint
F0684 Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0686 Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Apr 5, 2024 · CMS health inspection
-
Serious
Scope/severity G
Complaint
F0688 Quality of Life and Care Deficiencies
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 Apr 5, 2024 · CMS health inspection
-
Serious
Scope/severity G
Complaint
F0689 Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0690 Quality of Life and Care Deficiencies
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 Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0692 Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Corrected Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0698 Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0711 Nursing and Physician Services Deficiencies
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0745 Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0757 Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0758 Pharmacy Service Deficiencies
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 Apr 5, 2024 · CMS health inspection
-
Serious
Scope/severity G
Complaint
F0760 Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Corrected Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0825 Quality of Life and Care Deficiencies
Provide or get specialized rehabilitative services as required for a resident.
Corrected Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity F
Complaint
F0880 Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Corrected Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0881 Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Corrected Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
Jan 17, 2024 Health · 10 findings
-
Not serious
Scope/severity E
Complaint
F0585 Resident Rights Deficiencies
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 Apr 5, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected Feb 9, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Corrected Feb 9, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0677 Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Apr 5, 2024 · CMS health inspection
-
Serious
Scope/severity G
Complaint
F0684 Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Apr 5, 2024 · CMS health inspection
-
Serious
Scope/severity G
Complaint
F0686 Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Apr 5, 2024 · CMS health inspection
-
Serious
Scope/severity J
Complaint
F0689 Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Apr 5, 2024 · CMS health inspection
-
Serious
Scope/severity G
Complaint
F0697 Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Corrected Feb 9, 2024 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0943 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected Feb 9, 2024 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0947 Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected Feb 9, 2024 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
-
Nov 1, 2023 Health · 24 findings
-
Not serious
Scope/severity E
Complaint
F0550 Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0551 Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0554 Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0558 Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity F
Complaint
F0584 Resident Rights Deficiencies
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 Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0585 Resident Rights Deficiencies
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 Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0625 Resident Rights Deficiencies
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 Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0656 Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0657 Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0677 Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0684 Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0689 Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0690 Quality of Life and Care Deficiencies
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 Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0691 Quality of Life and Care Deficiencies
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0755 Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0759 Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0803 Nutrition and Dietary Deficiencies
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 Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0804 Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0807 Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity F
Complaint
F0809 Nutrition and Dietary Deficiencies
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 Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0880 Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0921 Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected Dec 1, 2023 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
-
Apr 26, 2023 Health · 35 findings
-
Not serious
Scope/severity D
F0550 Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0553 Resident Rights Deficiencies
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0578 Resident Rights Deficiencies
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 May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity E
F0623 Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity E
F0625 Resident Rights Deficiencies
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 May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity E
F0656 Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0677 Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0684 Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0686 Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0688 Quality of Life and Care Deficiencies
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 May 19, 2023 · CMS health inspection
-
Serious
Scope/severity G
F0689 Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity E
F0692 Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0755 Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0758 Pharmacy Service Deficiencies
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 May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity E
F0761 Pharmacy Service Deficiencies
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 May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity F
F0812 Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0842 Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0849 Administration Deficiencies
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 May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity E
F0880 Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0883 Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected May 19, 2023 · CMS health inspection
-
Not serious
Scope/severity E
K0211 Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected May 24, 2023 · CMS fire safety
-
Not serious
Scope/severity D
K0222 Egress Deficiencies
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 May 24, 2023 · CMS fire safety
-
Not serious
Scope/severity E
K0311 Smoke Deficiencies
Have an enclosure around a vertical opening shaft.
Corrected May 24, 2023 · CMS fire safety
-
Not serious
Scope/severity D
K0324 Smoke Deficiencies
Provide properly protected cooking facilities.
Corrected May 24, 2023 · CMS fire safety
-
Not serious
Scope/severity F
K0341 Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Corrected Jun 14, 2023 · CMS fire safety
-
Not serious
Scope/severity D
K0345 Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected May 24, 2023 · CMS fire safety
-
Not serious
Scope/severity F
K0346 Smoke Deficiencies
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected May 24, 2023 · CMS fire safety
-
Not serious
Scope/severity D
K0353 Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Corrected May 24, 2023 · CMS fire safety
-
Not serious
Scope/severity E
K0374 Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected May 24, 2023 · CMS fire safety
-
Not serious
Scope/severity E
K0741 Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected May 24, 2023 · CMS fire safety
-
Not serious
Scope/severity E
K0781 Miscellaneous Deficiencies
Have restrictions on the use of portable space heaters.
Corrected May 24, 2023 · CMS fire safety
-
Not serious
Scope/severity F
K0916 Gas, Vacuum, and Electrical Systems Deficiencies
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected May 24, 2023 · CMS fire safety
-
Not serious
Scope/severity E
K0920 Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Corrected May 24, 2023 · CMS fire safety
-
Not serious
Scope/severity D
Owners and managers (as published by CMS)
- JEIDEL, JACOB — 5% or greater direct ownership interest, 60%, since 01/01/2023
- JEIDEL, JACOB — corporate officer, NOT APPLICABLE, since 01/01/2023
- KLEKAMP, STEVE — w-2 managing employee, NOT APPLICABLE, since 01/01/2023
- SHKOP, BENJAMIN — 5% or greater direct ownership interest, 20%, since 01/01/2023
Sources: Wisconsin Department of Health Services (directory, assisted-living survey documents) and CMS Care Compare (nursing homes). “Harm or jeopardy level” is CMS scope/severity G–L. About this data.