Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Greentree Health and Rehabilitation Center

Clintonville, WI · 50 certified beds · Last Life Safety survey April 23, 2025

CMS Certification Number 525348 · first certified February 1984

Ownership

Operated by THE ENSIGN GROUP · For profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

15
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
2
Tags cited more than once
Across separate surveys
7
Inspection & testing records
Of the citations on file

Position within WI

15 citations — more than 38% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 3 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (June 2026 to July 2026), and past the point by which nine in ten WI facilities have been surveyed. This facility’s last Life Safety survey was April 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

1 of the 15 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.

This facility15WI median17National median11
Citations on file over three years, compared
MeasureCitations
This facility15
Median facility in WI17
Median facility nationally11

Survey history

Citations at each Life Safety survey
32023-0292024-0232025-04
Citations at each Life Safety survey
Survey dateCitations
February 15, 20233
February 21, 20249
April 23, 20253

Most-cited tags

Most-cited tags at this facility
K-03213K-03532K-03721K-09231K-03451K-03541K-02321E-00361
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.32025-04-23
K-0353Inspect, test, and maintain automatic sprinkler systems.22025-04-23
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.12024-02-21
K-0923Have proper medical gas storage and administration areas.12024-02-21
K-0345Have approved installation, maintenance and testing program for fire alarm systems.12024-02-21
K-0354Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.12024-02-21
K-0232Have corridors or aisles that are unobstructed and are at least 8 feet in width.12024-02-21
E-0036Establish emergency prep training and testing.12023-02-15

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 10
  • Gas, Vacuum, and Electrical Systems Deficiencies 2
  • Emergency Preparedness Deficiencies 1
  • Services Deficiencies 1
  • Other 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies10
Gas, Vacuum, and Electrical Systems Deficiencies2
Emergency Preparedness Deficiencies1
Services Deficiencies1
Egress Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

April 23, 2025 — 3 citations

Citations issued on April 23, 2025
TagWhat the surveyor checksStatus
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (May 2, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (May 2, 2025)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (May 2, 2025)

February 21, 2024 — 9 citations

Citations issued on February 21, 2024
TagWhat the surveyor checksStatus
K-0232Have corridors or aisles that are unobstructed and are at least 8 feet in width.Deficient, Provider has date of correction (March 15, 2024)
K-0311Have an enclosure around a vertical opening shaft.Deficient, Provider has date of correction (March 15, 2024)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (March 15, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (March 15, 2024)
K-0354Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.Deficient, Provider has date of correction (March 15, 2024)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (March 15, 2024)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (March 15, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (March 15, 2024)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (March 15, 2024)

February 15, 2023 — 3 citations

Citations issued on February 15, 2023
TagWhat the surveyor checksStatus
E-0036Establish emergency prep training and testing.Deficient, Provider has date of correction (March 14, 2023)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (May 4, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (March 14, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.