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Nursing Home Inspect > Wisconsin > Milwaukee County Data as of October 2024

    Southpointe Care And Rehab Center Llc

    For profit - Corporation  ·  4500 W Loomis Rd, Greenfield, WI 53220  ·  See home’s Medicare page

    Special Focus Facility Candidate
    Has a history of serious quality issues but has not been formally flagged by the government.
    Affiliated With Complete Care
    People or companies with an ownership interest in or managerial control of this home, according to CMS data.
    3.91
    Nurse hours/resident/day
    Reported total nurse staffing hours per resident per day.
    State Average: 4.0
    56.3%
    Nurse turnover
    The percentage of nursing staff who stopped working at the home over a 12-month period.
    State Average: 50.2%
    174
    Certified beds
    Qualifying beds in the certified provider or supplier facility.
    98
    Average residents/day
    Average number of residents based on daily census.
    Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
    Direct owners
    Pc Swi Holdco Llc (100%)
    Indirect owners
    Pc Swi Topco Llc
    Peace Capital Holdings Llc (De)
    Sms 2021 Trust
    Shalom Stein
    Managerial control
    No information available
    Managing employee(s)
    Nisanel Silverberg since Jun, 2022

    Inspection Reports

    70

    total deficiencies

    5

    infection-related deficiencies

    This home violated federal standards protecting residents from the spread of infections.

    Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
    Aug 17, 2023
    Standard report
    8 deficiencies
    (1 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    $89,824 Fine
    C

     to J
    J
    Full report
    Quality of Life and Care Deficiency — F0686
    Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    Severity
    Immediate jeopardy to resident health or safety
    Scope
    Few people affected
    Seriousness
    J
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    Immediate jeopardy to resident health or safety
    Scope
    Few people affected
    Seriousness
    J
    Quality of Life and Care Deficiency — F0692
    Failure to: Provide enough food/fluids to maintain a resident's health.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Infection Control Deficiency — F0880
    Failure to: Provide and implement an infection prevention and control program.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Nutrition and Dietary Deficiency — F0812
    Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0690
    Failure to: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0757
    Failure to: Ensure each resident's drug regimen must be free from unnecessary drugs.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0623
    Failure to: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C
    Jun 30, 2022
    Complaint report
    5 deficiencies
    D

     to G
    G
    Full report
    Quality of Life and Care Deficiency — F0686
    Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Resident Rights Deficiency — F0557
    Failure to: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0580
    Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
    Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0677
    Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Apr 7, 2022
    Complaint report
    1 deficiency
    $144,901 Fine
    1 Payment Suspension
    D
    Full report
    Resident Rights Deficiency — F0622
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Apr 7, 2022
    Standard report
    30 deficiencies
    (3 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    $144,901 Fine
    1 Payment Suspension
    C

     to K
    K
    Full report
    Quality of Life and Care Deficiency — F0678
    Failure to: Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident's advance directives.
    Severity
    Immediate jeopardy to resident health or safety
    Scope
    Some people affected
    Seriousness
    K
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    Immediate jeopardy to resident health or safety
    Scope
    Few people affected
    Seriousness
    J
    Resident Rights Deficiency — F0580
    Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Resident Rights Deficiency — F0583
    Failure to: Keep residents' personal and medical records private and confidential.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Infection Control Deficiency — F0880
    Failure to: Provide and implement an infection prevention and control program.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Quality of Life and Care Deficiency — F0695
    Failure to: Provide safe and appropriate respiratory care for a resident when needed.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Pharmacy Service Deficiency — F0761
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0842
    Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nursing and Physician Services Deficiency — F0947
    Failure to: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0623
    Failure to: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0625
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Pharmacy Service Deficiency — F0755
    Failure to: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nutrition and Dietary Deficiency — F0804
    Failure to: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0578
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0690
    Failure to: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0692
    Failure to: Provide enough food/fluids to maintain a resident's health.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0698
    Failure to: Provide safe, appropriate dialysis care/services for a resident who requires such services.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0700
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0730
    Failure to: Observe each nurse aide's job performance and give regular training.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0758
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Infection Control Deficiency — F0881
    Failure to: Implement a program that monitors antibiotic use.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0943
    Failure to: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
    Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
    Failure to: Respond appropriately to all alleged violations.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0677
    Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0745
    Failure to: Provide medically-related social services to help each resident achieve the highest possible quality of life.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0759
    Failure to: Ensure medication error rates are not 5 percent or greater.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0760
    Failure to: Ensure that residents are free from significant medication errors.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Infection Control Deficiency — F0886
    Failure to: Perform COVID19 testing on residents and staff.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C
    Jan 12, 2022
    Complaint report
    5 deficiencies
    $7,933 Fine
    1 Payment Suspension
    D

     to J
    J
    Full report
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    Immediate jeopardy to resident health or safety
    Scope
    Few people affected
    Seriousness
    J
    Nursing and Physician Services Deficiency — F0947
    Failure to: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Resident Rights Deficiency — F0585
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0686
    Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0760
    Failure to: Ensure that residents are free from significant medication errors.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Oct 27, 2021
    Complaint report
    2 deficiencies
    D
    Full report
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0692
    Failure to: Provide enough food/fluids to maintain a resident's health.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Oct 13, 2021
    Complaint report
    8 deficiencies
    $23,474 Fine
    1 Payment Suspension
    D

     to G
    G
    Full report
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Resident Rights Deficiency — F0584
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0677
    Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0550
    Failure to: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
    Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
    Failure to: Respond appropriately to all alleged violations.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0698
    Failure to: Provide safe, appropriate dialysis care/services for a resident who requires such services.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0760
    Failure to: Ensure that residents are free from significant medication errors.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Mar 5, 2020
    Standard report
    11 deficiencies
    (1 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    D

     to J
    J
    Full report
    Quality of Life and Care Deficiency — F0686
    Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    Severity
    Immediate jeopardy to resident health or safety
    Scope
    Few people affected
    Seriousness
    J
    Nutrition and Dietary Deficiency — F0812
    Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Infection Control Deficiency — F0880
    Failure to: Provide and implement an infection prevention and control program.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Quality of Life and Care Deficiency — F0688
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0677
    Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0690
    Failure to: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0693
    Failure to: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0757
    Failure to: Ensure each resident's drug regimen must be free from unnecessary drugs.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0758
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D

    Penalties

    $276K

    total fines

    3

    payment suspensions

    A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
    Aug 17, 2023
    $89,824 fine
    Jul 25, 2022
    $2,466 fine
    No corresponding inspection report.
    Jul 18, 2022
    $2,113 fine
    No corresponding inspection report.
    Jul 11, 2022
    $1,748 fine
    No corresponding inspection report.
    Jun 21, 2022
    $3,145 fine
    No corresponding inspection report.
    Apr 7, 2022
    $144,901 fine
    1 Payment Suspension
    Jan 12, 2022
    $7,933 fine
    1 Payment Suspension
    Oct 13, 2021
    $23,474 fine
    1 Payment Suspension