Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MIDDLETON VILLAGE NURSING AND REHAB
MIDDLETON, WI · 97 certified beds · Last Life Safety survey March 5, 2026
CMS Certification Number 525330 · first certified December 1982
Ownership
Operated by SHLOMO HOFFMAN · For profit - Individual
- Ownership changed January 1, 2023 (change of ownership)to MIDDLETON VILLAGE NURSING AND REHAB LLC from VILLA AT MIDDLETON VILLAGE, LLC
Position within WI
32 citations — more than 88% 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
The latest survey found 9 citations; the earlier surveys in the window averaged 11.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens April 2027 — about 7 months from now. This facility’s last Life Safety survey was March 2026. 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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3 inspection-and-testing tags have 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
3 of the 32 citations on file are 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)
8 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 32 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- 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
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 32 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 26, 2023 | 11 |
| October 28, 2024 | 12 |
| March 5, 2026 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2026-03-05 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-03-05 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 3 | 2026-03-05 |
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2026-03-05 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2026-03-05 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2026-03-05 |
| K-0222 | 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. | 1 | 2026-03-05 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-10-28 |
What the citations cover
- Smoke Deficiencies 16
- Egress Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Services Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 16 |
| Egress Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Services Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 3 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 5, 2026 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (March 5, 2026) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0222 | 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. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0321 | Ensure 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 20, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (April 15, 2026) |
October 28, 2024 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (November 11, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (November 11, 2024) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (November 19, 2024) |
| K-0321 | Ensure 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 (November 19, 2024) |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 19, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 19, 2024) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (November 19, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 19, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (November 19, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (November 19, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 19, 2024) |
October 26, 2023 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (November 17, 2023) |
| K-0321 | Ensure 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 (November 17, 2023) |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (December 4, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (November 21, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (August 12, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 8, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (November 17, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (November 17, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (November 17, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 17, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.