West Allis, WI

Aria At Mitchell Manor

3-star overall rating with 3-star inspections with $15,872 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

5301 W Lincoln Ave, West Allis, WI

(414) 615-7100

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

50

Certified beds

Average residents

46

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Aria Healthcare

Operator or chain grouping

Approved since

1996-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

5 facilities

Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.41

Registered nurse staffing · state 0.97 · national 0.68

LPN hours / resident day

1.19

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.36

Nurse aide staffing · state 2.59 · national 2.35

Total nurse hours

3.97

All reported nurse hours · state 4.20 · national 3.89

Licensed hours

1.61

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.18

Weekend nurse staffing · state 3.72 · national 3.43

Weekend RN hours

0.19

Weekend registered nurse coverage · state 0.66 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.36

CMS adjusted RN staffing hours

Adjusted total hours

3.45

CMS adjusted total nurse staffing hours

Case-mix index

1.57

Higher values indicate more complex resident acuity

RN turnover

43%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

44%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,107

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

21.41

Composite VBP score used to determine payment impact.

Payment multiplier

0.9826

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.25

Baseline 20.77% · Performance 20.39% · Measure score 2.25 · Achievement 2.25 · Improvement 0.51

Healthcare-associated infections

0

Baseline 8.12% · Performance 8.64% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

4.25

Baseline 49.09% · Performance 46.30% · Measure score 4.25 · Achievement 4.25 · Improvement 0.65

Adjusted total nurse staffing

2.07

Baseline 3.66 hours · Performance 3.67 hours · Measure score 2.07 · Achievement 2.07 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.81%	10.72% 0.1 pts worse	No Different than the National Rate · Eligible stays 70 · Observed rate 12.86% · Lower 95% interval 7.14%
Discharge to community	54.1%	50.57% 3.5 pts better	No Different than the National Rate · Eligible stays 62 · Observed rate 43.55% · Lower 95% interval 41.42%
Medicare spending per beneficiary	1.03	1.02 About the same
Drug regimen review with follow-up	90%	95.27% 5.3 pts worse	Numerator 27 · Denominator 30
Falls with major injury	3.33%	0.77% 2.6 pts worse	Numerator 1 · Denominator 30
Discharge self-care score	60.87%	53.69% 7.2 pts better	Numerator 14 · Denominator 23
Discharge mobility score	52.17%	50.94% 1.2 pts better	Numerator 12 · Denominator 23
Pressure ulcers or injuries, new or worsened	6.67%	2.29% 4.4 pts worse	Numerator 2 · Denominator 30 · Adjusted rate 7.79%
Healthcare-associated infections requiring hospitalization	8.64%	7.12% 1.5 pts worse	No Different than the National Rate · Eligible stays 37 · Observed rate 16.22% · Lower 95% interval 4.21%
Staff COVID-19 vaccination coverage	24.64%	8.2% 16.4 pts better	Numerator 17 · Denominator 69
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	56.52%	56.45% 0.1 pts better	Numerator 13 · Denominator 23
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.9%	95.7% 2.2 pts better	93.4% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.2% · Q4 94.9% · 4Q avg 97.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.2%	95.0% 0.2 pts better	95.5% 0.3 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2%
Percentage of long-stay residents experiencing one or more falls with major injury	4.1%	3.2% 0.9 pts worse	3.3% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 2.9% · Q3 2.8% · Q4 2.6% · 4Q avg 4.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	10.8%	5.0% 5.8 pts worse	11.4% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 17.6% · Q3 9.1% · Q4 8.1% · 4Q avg 10.8%
Percentage of long-stay residents who lose too much weight	12.0%	4.9% 7.1 pts worse	5.4% 6.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 14.3% · Q3 14.7% · Q4 11.8% · 4Q avg 12.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.6%	16.6% 1 pts better	19.6% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 17.2% · Q3 14.3% · Q4 20.0% · 4Q avg 15.6%
Percentage of long-stay residents who received an antipsychotic medication	15.9%	16.7% 0.8 pts better	16.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 16.7% · Q3 19.4% · Q4 6.5% · 4Q avg 15.9% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	20.2%	21.1% 0.9 pts better	16.3% 3.9 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 20.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	17.1%	17.3% 0.2 pts better	14.9% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 3.6% · Q3 23.5% · Q4 28.1% · 4Q avg 17.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	3.7%	2.3% 1.4 pts worse	1.0% 2.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 3.6% · Q4 5.6% · 4Q avg 3.7% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.8%	3.0% 0.2 pts better	1.7% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.7% · Q4 5.3% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	26.9%	25.5% 1.4 pts worse	19.8% 7.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 24.6% · Q3 19.8% · Q4 26.4% · 4Q avg 26.9%
Percentage of long-stay residents with pressure ulcers	5.5%	5.5% About the same	5.1% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 3.1% · Q3 4.1% · Q4 8.3% · 4Q avg 5.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	91.4%	86.8% 4.6 pts better	81.7% 9.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 91.5% · Q3 87.7% · Q4 90.9% · 4Q avg 91.4%
Percentage of short-stay residents who had an outpatient emergency department visit	3.1%	15.0% 11.9 pts better	12.0% 8.9 pts better	Short Stay · 20240701-20250630 · Adjusted 3.1% · Observed 3.4% · Expected 12.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.6%	1.3% 0.7 pts better	1.6% 1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	77.0%	82.2% 5.2 pts worse	79.7% 2.7 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 77.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	18.8%	22.7% 3.9 pts better	23.9% 5.1 pts better	Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 20.7% · Expected 26.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-29 · Fire 2025-01-29

4 health deficiencies

Top issue: Infection Control (2 deficiencies)

6 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Cycle 2 Health 2023-10-16 · Fire 2023-10-16

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2022-07-21 · Fire 2022-07-21

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-29

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2025-02-20

F · Potential for more than minimal harm 2025-01-29

E35 · Emergency Preparedness Deficiencies

Fire Safety

Provide family notifications of emergency plan.

Corrected 2025-02-20

F · Potential for more than minimal harm 2025-01-29

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2025-02-20

F · Potential for more than minimal harm 2025-01-29

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-02-20

D · Potential for more than minimal harm 2025-01-29

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-02-20

D · Potential for more than minimal harm 2025-01-29

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-02-20

E · Potential for more than minimal harm 2023-10-16

K132 · Construction Deficiencies

Fire Safety

Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

Corrected 2023-11-07

D · Potential for more than minimal harm 2023-10-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-11-07

D · Potential for more than minimal harm 2023-10-16

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-11-06

C · Minimal harm 2023-10-16

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-11-07

F · Potential for more than minimal harm 2022-07-21

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-08-12

E · Potential for more than minimal harm 2022-07-21

K221 · Egress Deficiencies

Fire Safety

Provide rooms that can be unlocked from inside without a key.

Corrected 2022-08-12

E · Potential for more than minimal harm 2022-07-21

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2022-08-12

D · Potential for more than minimal harm 2022-07-21

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-08-12

D · Potential for more than minimal harm 2022-07-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-08-12

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-04-09

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2025-05-02

F · Potential for more than minimal harm 2025-01-29

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-20

E · Potential for more than minimal harm 2025-01-29

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2025-02-20

D · Potential for more than minimal harm 2025-01-29

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-02-20

D · Potential for more than minimal harm 2024-11-25

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-12-20

E · Potential for more than minimal harm 2024-08-26

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-09-16

J · Immediate jeopardy 2023-10-16

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-11-07

F · Potential for more than minimal harm 2023-10-16

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-11-07

F · Potential for more than minimal harm 2023-10-16

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2023-11-07

E · Potential for more than minimal harm 2023-10-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-11-07

D · Potential for more than minimal harm 2023-10-16

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-11-07

F · Potential for more than minimal harm 2023-08-07

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2023-08-23

F · Potential for more than minimal harm 2023-08-07

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2023-08-23

D · Potential for more than minimal harm 2023-05-26

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-06-20

F · Potential for more than minimal harm 2022-07-21

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-08-14

E · Potential for more than minimal harm 2022-07-21

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2022-08-14

D · Potential for more than minimal harm 2022-07-21

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2022-08-14

D · Potential for more than minimal harm 2022-07-21

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-08-14

D · Potential for more than minimal harm 2022-07-21

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-08-14

D · Potential for more than minimal harm 2022-07-21

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2022-08-14

Penalties and ownership

What sits behind the stars

$15,872 2023-10-16

Fine

Fine · fine $15,872

Fine