Bradley Estates Nursing and Rehab LLC
6735 W Bradley Rd, Milwaukee, WI 53223
Bradley Estates Nursing and Rehab LLC is a nursing home in Milwaukee, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionSeptember 17, 2025 (1 year ago)
- Health citations since April 26, 2023156 (Wisconsin average 28)
- Fines in the past three years4, $305,374 in total
- CMS flagsSpecial Focus Facility candidate, CMS abuse icon
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CMS flags
Special Focus Facility candidate
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Health inspection on July 9, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on July 30, 2026.
CMS has cited this home for F0600 4 times since 2025.
CMS update of May 27, 2026
Fine
CMS changed the fine from January 7, 2025 from $122,110 to $79,372.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
Health inspection on December 30, 2025
4 citationsCMS lists this as a complaint inspection.
Show the 4 citations
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on January 28, 2026.
CMS has cited this home for F0584 3 times since 2023.
Citation F0565. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on January 28, 2026.
CMS has cited this home for F0565 2 times since 2025.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on January 28, 2026.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on January 28, 2026.
CMS has cited this home for F0610 7 times since 2023.
Health inspection on September 17, 2025
15 citationsCMS lists this as a standard inspection.
Show the 15 citations
Citation F0605. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on October 16, 2025.
Citation F0641. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on October 16, 2025.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0761 4 times since 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0880 8 times since 2023.
Citation F0551. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give the resident's representative the ability to exercise the resident's rights.
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0551 2 times since 2023.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0552 2 times since 2024.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on October 16, 2025.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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 lists it as corrected on October 16, 2025.
CMS has cited this home for F0585 5 times since 2023.
Citation F0640. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
CMS lists it as corrected on October 16, 2025.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on October 16, 2025.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0645 2 times since 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0677 7 times since 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0686 5 times since 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0689 8 times since 2023.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0757 3 times since 2024.
Fire safety inspection on September 17, 2025
9 citationsCMS lists this as a standard inspection.
Show the 9 citations
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on October 15, 2025.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on October 3, 2025.
CMS has cited this home for K0222 2 times since 2023.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on October 3, 2025.
CMS has cited this home for K0321 2 times since 2024.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for K0353 3 times since 2023.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on October 10, 2025.
CMS has cited this home for K0511 2 times since 2024.
Citation K0753. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on October 10, 2025.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on October 3, 2025.
Citation K0541. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on March 20, 2026.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on October 10, 2025.
CMS has cited this home for K0920 3 times since 2023.
Health inspection on August 20, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on September 14, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on September 14, 2025.
CMS has cited this home for F0609 5 times since 2023.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on September 14, 2025.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.3 to 3.7 hours per resident per day.
Health inspection on July 11, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on August 8, 2025.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on August 8, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 8, 2025.
CMS update of June 25, 2025
Health citation
CMS removed citation F0625 from the health inspection on February 6, 2025.
Health citation
CMS removed citation F0626 from the health inspection on February 6, 2025.
Health inspection on June 10, 2025
4 citationsCMS lists this as a complaint inspection.
Show the 4 citations
Citation F0565. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on July 4, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on July 4, 2025.
CMS has cited this home for F0755 4 times since 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 4, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 4, 2025.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Health inspection on April 1, 2025
8 citationsCMS lists this as a complaint inspection.
Show the 8 citations
Citation F0801. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on April 10, 2025.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on April 10, 2025.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 10, 2025.
Citation F0803. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 10, 2025.
CMS has cited this home for F0803 2 times since 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 10, 2025.
CMS has cited this home for F0812 2 times since 2023.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on April 10, 2025.
CMS has cited this home for F0580 4 times since 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on April 10, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 10, 2025.
CMS update of March 26, 2025
Ownership
CMS lists this home under a new chain.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Health inspection on February 6, 2025
4 citationsCMS lists this as a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.
CMS stopped payment for new admissions from February 6, 2025, for 1 day.
Show the 4 citations
Citation F0689. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on February 7, 2025.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on February 7, 2025.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 7, 2025.
CMS has cited this home for F0625 4 times since 2023.
Citation F0626. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
CMS lists it as corrected on February 7, 2025.
Health inspection on January 7, 2025
4 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
77 of 323 Wisconsin homes (24%) got a citation at the actual harm level in 2025.
CMS fine of $79,372 on January 7, 2025.
Show the 4 citations
Citation F0690. Severity G: actual harm, isolated.
The rule CMS cited:
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 lists it as corrected on February 4, 2025.
CMS has cited this home for F0690 3 times since 2023.
Citation F0607. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on January 21, 2025.
CMS has cited this home for F0607 4 times since 2023.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on January 21, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on February 7, 2025.
CMS update of December 20, 2024
Fine
CMS changed the fine from January 17, 2024 from $16,801 to $17,101.
Fine
CMS changed the fine from January 17, 2024 from $40,541 to $41,266.
Health inspection on October 28, 2024
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0622. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 29, 2024.
CMS has cited this home for F0622 2 times since 2024.
Citation F0685. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on October 31, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 19, 2024.
Health inspection on September 19, 2024
10 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
67 of 323 Wisconsin homes (21%) got a citation at the actual harm level in 2024.
Show the 10 citations
Citation F0760. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on December 5, 2024.
CMS has cited this home for F0760 2 times since 2024.
Citation F0553. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
CMS lists it as corrected on October 14, 2024.
CMS has cited this home for F0553 2 times since 2023.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on October 14, 2024.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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 lists it as corrected on October 17, 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on October 14, 2024.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on October 14, 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on December 5, 2024.
CMS has cited this home for F0657 3 times since 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on October 16, 2024.
CMS has cited this home for F0692 3 times since 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 14, 2024.
CMS has cited this home for F0758 3 times since 2023.
Citation F0917. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 17, 2024.
CMS update of August 29, 2024
Fine
CMS changed the fine from February 10, 2022 from $16,287 to $16,679.
Fine
CMS changed the fine from January 17, 2024 from $25,847 to $16,801.
Fine
CMS changed the fine from January 17, 2024 from $62,370 to $40,541.
August 10, 2024
Payment stoppedCMS stopped payment for new admissions from August 10, 2024, for 117 days.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on July 1, 2024
21 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
64 of 323 Wisconsin homes (20%) got a citation at the immediate jeopardy level in 2024.
CMS fine of $167,635 on July 1, 2024.
Show the 21 citations
Citation F0745. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on July 17, 2024.
CMS has cited this home for F0745 2 times since 2024.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on December 5, 2024.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 17, 2024.
Citation F0908. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep all essential equipment working safely.
CMS lists it as corrected on July 17, 2024.
Citation F0944. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on July 17, 2024.
Citation F0946. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide training in compliance and ethics.
CMS lists it as corrected on July 17, 2024.
Citation F0607. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on July 17, 2024.
Citation F0610. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on July 17, 2024.
Citation F0623. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on July 17, 2024.
CMS has cited this home for F0623 2 times since 2023.
Citation F0625. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 17, 2024.
Citation F0645. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on July 17, 2024.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on July 17, 2024.
Citation F0602. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from the wrongful use of the resident's belongings or money.
CMS lists it as corrected on July 17, 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 17, 2024.
Citation F0622. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 17, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 17, 2024.
CMS has cited this home for F0656 3 times since 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on July 17, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 17, 2024.
CMS has cited this home for F0684 5 times since 2023.
Citation F0700. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 17, 2024.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on July 17, 2024.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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 lists it as corrected on July 17, 2024.
CMS has cited this home for F0849 2 times since 2023.
Fire safety inspection on July 1, 2024
12 citationsCMS lists this as a standard inspection.
Show the 12 citations
Citation E0020. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures including evacuation.
CMS lists it as corrected on July 17, 2024.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on July 17, 2024.
Citation K0711. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on July 17, 2024.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on July 17, 2024.
CMS has cited this home for K0211 2 times since 2023.
Citation K0347. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly provide smoke detection systems in areas open to corridors.
CMS lists it as corrected on July 17, 2024.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on July 17, 2024.
CMS has cited this home for K0374 2 times since 2023.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on July 17, 2024.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on July 17, 2024.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on February 4, 2025.
CMS has cited this home for K0324 2 times since 2023.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on July 17, 2024.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on July 17, 2024.
CMS has cited this home for K0741 2 times since 2023.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on July 17, 2024.
CMS update of May 29, 2024
Fine
CMS changed the fine from February 10, 2022 from $15,000 to $16,287.
CMS update of March 28, 2024
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
Health inspection on March 7, 2024
20 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
67 of 323 Wisconsin homes (21%) got a citation at the actual harm level in 2024.
Show the 20 citations
Citation F0684. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 5, 2024.
Citation F0688. Severity G: actual harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 5, 2024.
CMS has cited this home for F0688 2 times since 2023.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 5, 2024.
Citation F0760. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on April 5, 2024.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 5, 2024.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on April 5, 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on April 5, 2024.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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 lists it as corrected on April 5, 2024.
Citation F0661. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
CMS lists it as corrected on April 5, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on April 5, 2024.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 5, 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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 lists it as corrected on April 5, 2024.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 5, 2024.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on April 5, 2024.
Citation F0711. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
CMS lists it as corrected on April 5, 2024.
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on April 5, 2024.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on April 5, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 5, 2024.
Citation F0825. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or get specialized rehabilitative services as required for a resident.
CMS lists it as corrected on April 5, 2024.
Citation F0881. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on April 5, 2024.
CMS update of February 29, 2024
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
February 16, 2024
Payment stoppedCMS stopped payment for new admissions from February 16, 2024, for 49 days.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
Fine
CMS changed the fine from December 29, 2022 from $163,800 to $106,470.
Health inspection on January 17, 2024
10 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
64 of 323 Wisconsin homes (20%) got a citation at the immediate jeopardy level in 2024.
CMS fine of $17,101 on January 17, 2024.
CMS fine of $41,266 on January 17, 2024.
Show the 10 citations
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 5, 2024.
Citation F0684. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 5, 2024.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 5, 2024.
Citation F0697. Severity G: actual harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on February 9, 2024.
Citation F0585. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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 lists it as corrected on April 5, 2024.
Citation F0943. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on February 9, 2024.
Citation F0947. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on February 9, 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on February 9, 2024.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on February 9, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on April 5, 2024.
Health inspection on November 1, 2023
24 citationsCMS lists this as a complaint inspection.
Show the 24 citations
Citation F0584. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on December 1, 2023.
Citation F0809. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on December 1, 2023.
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on December 1, 2023.
CMS has cited this home for F0550 2 times since 2023.
Citation F0585. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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 lists it as corrected on December 1, 2023.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 1, 2023.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 1, 2023.
Citation F0690. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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 lists it as corrected on December 1, 2023.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on December 1, 2023.
Citation F0803. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on December 1, 2023.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on December 1, 2023.
Citation F0807. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
CMS lists it as corrected on December 1, 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 1, 2023.
Citation F0551. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give the resident's representative the ability to exercise the resident's rights.
CMS lists it as corrected on December 1, 2023.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on December 1, 2023.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on December 1, 2023.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on December 1, 2023.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on December 1, 2023.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 1, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on December 1, 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on December 1, 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on December 1, 2023.
Citation F0691. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
CMS lists it as corrected on December 1, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on December 1, 2023.
Citation F0921. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on December 1, 2023.
Health inspection on April 26, 2023
22 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
42 of 323 Wisconsin homes (13%) got a citation at the actual harm level in 2023.
Show the 22 citations
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 19, 2023.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 19, 2023.
Citation F0623. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on May 19, 2023.
Citation F0625. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 19, 2023.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on May 19, 2023.
Citation F0692. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on May 19, 2023.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 19, 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 19, 2023.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on May 19, 2023.
Citation F0553. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
CMS lists it as corrected on May 19, 2023.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 19, 2023.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on May 19, 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on May 19, 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on May 19, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 19, 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on May 19, 2023.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 19, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 19, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 19, 2023.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on May 19, 2023.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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 lists it as corrected on May 19, 2023.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on May 19, 2023.
Fire safety inspection on April 26, 2023
13 citationsCMS lists this as a standard inspection.
Show the 13 citations
Citation K0341. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on June 14, 2023.
Citation K0346. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
CMS lists it as corrected on May 24, 2023.
Citation K0916. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a battery powered remote alarm panel in a location accessible by operating personnel.
CMS lists it as corrected on May 24, 2023.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on May 24, 2023.
Citation K0311. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
CMS lists it as corrected on May 24, 2023.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on May 24, 2023.
Citation K0741. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on May 24, 2023.
Citation K0781. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on May 24, 2023.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on May 24, 2023.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 24, 2023.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on May 24, 2023.
Citation K0345. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on May 24, 2023.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 24, 2023.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (414) 354-3300
- Last standard health inspection
- September 17, 2025 (1 year ago)
- Certified beds
- 198
- Residents per day, on average
- 131
- Ownership type
- For profit - Corporation
- Legal business name
- Bradley Estates Nursing and Rehab LLC
- Chain
- Shlomo Hoffman
- Takes part in
- Medicare and Medicaid
More health citations than the Wisconsin average (156 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- JEIDEL, JACOB5% or greater direct ownership interest · 60% · since 01/01/2023
- SHKOP, BENJAMIN5% or greater direct ownership interest · 20% · since 01/01/2023
Questions
When was Bradley Estates Nursing and Rehab LLC last inspected?
CMS lists September 17, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Bradley Estates Nursing and Rehab LLC have?
CMS lists 156 health citations since April 26, 2023. CMS also calls these deficiencies.
Has Bradley Estates Nursing and Rehab LLC been fined?
CMS lists 4 fines in the past three years, $305,374 in total.
What is the CMS star rating of Bradley Estates Nursing and Rehab LLC?
Its CMS overall star rating is 1 of 5.
Is Bradley Estates Nursing and Rehab LLC a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility candidate.