Complete Care At Maple Grove LLC
Nursing home · 3401 Maple Grove Dr., Madison, WI 53719 · Dane County
Prices
No published price is available. Ask the facility directly.
Facility
- Type
- Nursing home · TITLE 18 SNF TITLE 19 NF
- Capacity
- 184
- State license
- 3101
- Medicare CCN
- 525276
- Licensed entity
- ST MARYS CARE AND REHAB CENTER LLC
- Chain
- COMPLETE CARE
- Ownership
- For profit - Corporation
- Phone
- (608) 845-1000
- Nurse staffing
- 4.97 hours per resident per day; 64.0% nursing staff turnover
- Medicare ratings
- Inspections 1★ · Staffing 4★ · Quality 4★
- Official record
- Wisconsin DQA Provider Search
- Official record
- Medicare Care Compare
Penalties
- May 5, 2025 — Payment Denial · payment denial 21 days
- May 5, 2025 — Fine ($58,354)
- Mar 28, 2025 — Fine ($34,356)
- Oct 21, 2024 — Payment Denial · payment denial 8 days
- Oct 21, 2024 — Fine ($12,048)
- Sep 12, 2024 — Fine ($15,642)
- Dec 4, 2023 — Fine ($18,018)
- Dec 4, 2023 — Fine ($15,239)
- Dec 4, 2023 — Payment Denial · payment denial 48 days
Inspection findings
-
Jul 2, 2026 Health · 11 findings
-
Not serious
Scope/severity D
Complaint
F0554 Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
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.
CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0645 Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0677 Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
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.
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.
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.
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.
CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0699 Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
CMS health inspection
-
Not serious
Scope/severity F
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.
CMS health inspection
-
Not serious
Scope/severity D
Complaint
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.
CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
Jun 25, 2026 Health · 1 finding
-
Not serious
Scope/severity D
Complaint
F0760 Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Corrected Jul 23, 2026 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
Jul 29, 2025 Health · 1 finding
-
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 12, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
May 5, 2025 Fire Safety · 27 findings
-
Not serious
Scope/severity F
E0004 Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Corrected Jun 24, 2025 · CMS fire safety
-
Not serious
Scope/severity F
E0006 Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Corrected Jun 24, 2025 · CMS fire safety
-
Not serious
Scope/severity F
E0039 Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Corrected Jun 24, 2025 · CMS fire safety
-
Not serious
Scope/severity E
F0550 Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected Jun 9, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0554 Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected Jun 9, 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 Jun 9, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0604 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected Jun 9, 2025 · 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 Jun 9, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0660 Resident Assessment and Care Planning Deficiencies
Plan the resident's discharge to meet the resident's goals and needs.
Corrected Jun 9, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0675 Quality of Life and Care Deficiencies
Honor each resident's preferences, choices, values and beliefs.
Corrected Jun 9, 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 Jun 9, 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 Jun 9, 2025 · 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 Jun 9, 2025 · CMS health inspection
-
Not serious
Scope/severity D
F0697 Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Corrected Jun 9, 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 Jun 9, 2025 · 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 Jun 9, 2025 · CMS health inspection
-
Not serious
Scope/severity E
K0331 Smoke Deficiencies
Construct fire resistant interior walls.
Corrected Jun 24, 2025 · CMS fire safety
-
Not serious
Scope/severity D
K0351 Smoke Deficiencies
Install an approved automatic sprinkler system.
Corrected Jun 24, 2025 · CMS fire safety
-
Not serious
Scope/severity F
K0353 Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Corrected Jun 24, 2025 · CMS fire safety
-
Not serious
Scope/severity F
K0355 Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected Jun 24, 2025 · CMS fire safety
-
Not serious
Scope/severity E
K0362 Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected Jun 24, 2025 · CMS fire safety
-
Not serious
Scope/severity E
K0363 Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Corrected Jun 24, 2025 · CMS fire safety
-
Not serious
Scope/severity D
K0521 Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected Jun 24, 2025 · CMS fire safety
-
Not serious
Scope/severity F
K0761 Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected Jun 24, 2025 · CMS fire safety
-
Not serious
Scope/severity E
K0912 Gas, Vacuum, and Electrical Systems Deficiencies
Have power receptacles that are properly grounded.
Corrected Jun 24, 2025 · CMS fire safety
-
Not serious
Scope/severity F
K0918 Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Corrected Jun 24, 2025 · CMS fire safety
-
Not serious
Scope/severity E
K0919 Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the use of electrical equipment.
Corrected Jun 24, 2025 · CMS fire safety
-
Not serious
Scope/severity F
-
Mar 28, 2025 Health · 3 findings
-
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 26, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0805 Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected Apr 26, 2025 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
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 Apr 26, 2025 · CMS health inspection
-
Serious
Scope/severity G
Complaint
-
Nov 11, 2024 Health · 2 findings
-
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 Nov 23, 2024 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
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 Nov 23, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
Oct 21, 2024 Health · 2 findings
-
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 Nov 23, 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 Nov 15, 2024 · CMS health inspection
-
Serious
Scope/severity G
Complaint
-
Sep 12, 2024 Health · 2 findings
-
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 Oct 10, 2024 · CMS health inspection
-
Not serious
Scope/severity D
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 Oct 10, 2024 · CMS health inspection
-
Serious
Scope/severity J
Complaint
-
Jun 27, 2024 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 Jul 19, 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 Jul 19, 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 19, 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 Jul 19, 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 Jul 19, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0687 Quality of Life and Care Deficiencies
Provide appropriate foot care.
Corrected Jul 19, 2024 · 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 Jul 19, 2024 · 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 19, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
May 2, 2024 Fire Safety · 23 findings
-
Not serious
Scope/severity F
E0006 Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Corrected May 24, 2024 · CMS fire safety
-
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 May 24, 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 May 24, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0636 Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected May 24, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0641 Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Corrected May 24, 2024 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0645 Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected May 24, 2024 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0679 Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Corrected May 24, 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 May 24, 2024 · CMS health inspection
-
Not serious
Scope/severity C
Complaint
F0732 Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Corrected May 24, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0760 Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Corrected May 24, 2024 · 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 May 24, 2024 · CMS health inspection
-
Not serious
Scope/severity D
F0804 Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected May 24, 2024 · CMS health inspection
-
Not serious
Scope/severity F
Complaint
F0880 Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Corrected May 29, 2024 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0881 Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Corrected May 24, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0883 Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected May 24, 2024 · CMS health inspection
-
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 May 24, 2024 · CMS fire safety
-
Not serious
Scope/severity F
K0324 Smoke Deficiencies
Provide properly protected cooking facilities.
Corrected May 24, 2024 · CMS fire safety
-
Not serious
Scope/severity E
K0331 Smoke Deficiencies
Construct fire resistant interior walls.
Corrected May 24, 2024 · CMS fire safety
-
Not serious
Scope/severity D
K0351 Smoke Deficiencies
Install an approved automatic sprinkler system.
Corrected May 24, 2024 · CMS fire safety
-
Not serious
Scope/severity E
K0353 Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Corrected May 24, 2024 · CMS fire safety
-
Not serious
Scope/severity E
K0372 Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected May 24, 2024 · CMS fire safety
-
Not serious
Scope/severity D
K0918 Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Corrected Jun 14, 2024 · CMS fire safety
-
Not serious
Scope/severity E
K0927 Gas, Vacuum, and Electrical Systems Deficiencies
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected May 24, 2024 · CMS fire safety
-
Not serious
Scope/severity F
-
Apr 10, 2024 Health · 6 findings
-
Not serious
Scope/severity D
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 May 8, 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 May 8, 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 May 8, 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 May 8, 2024 · 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 May 8, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0759 Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Corrected May 8, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
Jan 8, 2024 Health · 2 findings
-
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 Feb 16, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
F0919 Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected Jan 17, 2024 · CMS health inspection
-
Serious
Scope/severity G
Complaint
-
Dec 4, 2023 Health · 3 findings
-
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 Dec 22, 2023 · CMS health inspection
-
Not serious
Scope/severity E
Complaint
F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Corrected Dec 22, 2023 · 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 Feb 16, 2024 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
Oct 9, 2023 Health · 3 findings
-
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 23, 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 Nov 2, 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 Oct 23, 2023 · CMS health inspection
-
Not serious
Scope/severity D
Complaint
-
Feb 27, 2023 Health · 24 findings
-
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 Mar 27, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0604 Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected Mar 27, 2023 · CMS health inspection
-
Not serious
Scope/severity E
F0677 Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Mar 27, 2023 · 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 Mar 27, 2023 · CMS health inspection
-
Not serious
Scope/severity D
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 Mar 27, 2023 · CMS health inspection
-
Not serious
Scope/severity E
F0725 Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected Mar 27, 2023 · 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 Mar 27, 2023 · CMS health inspection
-
Not serious
Scope/severity D
F0759 Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Corrected Mar 27, 2023 · CMS health inspection
-
Not serious
Scope/severity E
F0811 Nutrition and Dietary Deficiencies
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected Mar 27, 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 Mar 27, 2023 · CMS health inspection
-
Not serious
Scope/severity F
F0814 Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Corrected Mar 27, 2023 · CMS health inspection
-
Not serious
Scope/severity D
K0331 Smoke Deficiencies
Construct fire resistant interior walls.
Corrected Mar 27, 2023 · CMS fire safety
-
Not serious
Scope/severity E
K0345 Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected Jul 6, 2023 · CMS fire safety
-
Not serious
Scope/severity D
K0353 Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Corrected Mar 27, 2023 · CMS fire safety
-
Not serious
Scope/severity D
K0362 Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected Mar 27, 2023 · CMS fire safety
-
Not serious
Scope/severity D
K0363 Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Corrected Mar 27, 2023 · CMS fire safety
-
Not serious
Scope/severity D
K0372 Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected Mar 27, 2023 · CMS fire safety
-
Not serious
Scope/severity D
K0511 Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Corrected Mar 27, 2023 · CMS fire safety
-
Not serious
Scope/severity D
K0521 Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected Mar 27, 2023 · CMS fire safety
-
Not serious
Scope/severity E
K0712 Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Corrected Mar 27, 2023 · CMS fire safety
-
Not serious
Scope/severity F
K0761 Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected Apr 27, 2023 · CMS fire safety
-
Not serious
Scope/severity D
K0912 Gas, Vacuum, and Electrical Systems Deficiencies
Have power receptacles that are properly grounded.
Corrected Mar 27, 2023 · CMS fire safety
-
Not serious
Scope/severity F
K0914 Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected Apr 27, 2023 · CMS fire safety
-
Not serious
Scope/severity D
K0927 Gas, Vacuum, and Electrical Systems Deficiencies
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected Apr 27, 2023 · CMS fire safety
-
Not serious
Scope/severity D
Owners and managers (as published by CMS)
- CHOLES, DIANA — adp of the snf, NOT APPLICABLE, since 02/02/2005
- CHOLES, DIANA — operational/managerial control, NOT APPLICABLE, since 02/28/2025
- HELLMAN, YOSEF — managing control - governing body, NOT APPLICABLE, since 02/28/2025
- HELLMAN, YOSEF — operational/managerial control, NOT APPLICABLE, since 02/28/2025
- KLUGMAN, JACOB — indirect ownership interest, NOT APPLICABLE, since 02/28/2025
- KLUGMAN, JACOB — adp of the snf, NOT APPLICABLE, since 02/28/2025
- LEVERENTZ, LUANNE — adp of the snf, NOT APPLICABLE, since 02/28/2025
- MAINA, JENNIFER — operational/managerial control, NOT APPLICABLE, since 02/28/2025
- MAINA, JENNIFER — adp of the snf, NOT APPLICABLE, since 02/28/2025
- MURPHY, SEAN — adp of the snf, NOT APPLICABLE, since 02/28/2025
- MURPHY, SEAN — operational/managerial control, NOT APPLICABLE, since 02/28/2025
- STEIN, SHALOM — managing control - governing body, NOT APPLICABLE, since 02/28/2025
- STEIN, SHALOM — trustee of the snf, NOT APPLICABLE, since 02/28/2025
- STEIN, SHALOM — adp of the snf, NOT APPLICABLE, since 02/28/2025
- STEIN, SHALOM — indirect ownership interest, NOT APPLICABLE, since 02/28/2025
- STEIN, SHALOM — corporate officer, NOT APPLICABLE, since 02/28/2025
- STERNBUCH, DANIEL — adp of the snf, NOT APPLICABLE, since 02/28/2025
- STERNBUCH, DANIEL — operational/managerial control, NOT APPLICABLE, since 02/28/2025
- DES CAPITAL LLC — adp of the snf, NOT APPLICABLE, since 02/28/2025
- JRK INVESTMENTS LLC — adp of the snf, NOT APPLICABLE, since 02/28/2025
- PC WCM OPCO HOLDCO LLC — 5% or greater direct ownership interest, 100%, since 02/28/2025
- PC WCM PROPCO HOLDCO LLC — adp of the snf, NOT APPLICABLE, since 02/28/2025
- PC WCM TOPCO LLC — adp of the snf, NOT APPLICABLE, since 02/28/2025
- PC WCM TOPCO LLC — 5% or greater indirect ownership interest, since 02/28/2025
- PEACE CAPITAL HOLDINGS II LLC — adp of the snf, NOT APPLICABLE, since 02/28/2025
- PEACE CAPITAL HOLDINGS II LLC — 5% or greater indirect ownership interest, since 02/28/2025
- SMS 2021 TRUST — adp of the snf, NOT APPLICABLE, since 02/28/2025
- SMS 2021 TRUST — 5% or greater indirect ownership interest, since 02/28/2025
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.