Cycle 1
Health 2024-10-07 · Fire 2024-10-07
27 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Milwaukee, WI
Avina of Milwaukee
1-star overall rating with 1-star inspections with $90,921 in total fines with 27 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
9255 N 76th St, Milwaukee, WI
(414) 355-9300
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
82
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ascension Living
Operator or chain grouping
Approved since
1994-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 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
0.61
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.72
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
2.87
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.63
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
2.79
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,251
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.68% · Performance 21.54% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.79% · Performance 8.25% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.60
Baseline 55.42% · Performance 53.06% · Measure score 2.60 · Achievement 2.60 · Improvement 0.27
Adjusted total nurse staffing
4.41
Baseline 4.06 hours · Performance 4.33 hours · Measure score 4.41 · Achievement 4.41 · Improvement 1.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.75% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 85 · Observed rate 10.59% · Lower 95% interval 7.51% |
| Discharge to community | 52.92% |
50.57%
2.4 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 48.61% · Lower 95% interval 43.82% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 88.73% |
95.27%
6.5 pts worse
|
Numerator 63 · Denominator 71 |
| Falls with major injury | 1.41% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 71 |
| Discharge self-care score | 74.47% |
53.69%
20.8 pts better
|
Numerator 35 · Denominator 47 |
| Discharge mobility score | 48.94% |
50.94%
2 pts worse
|
Numerator 23 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 71 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.25% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 10.53% · Lower 95% interval 4.42% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 131 |
| Staff flu vaccination coverage | 56.5% |
42%
14.5 pts better
|
Numerator 113 · Denominator 200 |
| Discharge function score | 72.34% |
56.45%
15.9 pts better
|
Numerator 34 · Denominator 47 |
| Transfer of health information to provider | 80% |
95.95%
16 pts worse
|
Numerator 16 · Denominator 20 |
| Transfer of health information to patient | 88.89% |
96.28%
7.4 pts worse
|
Numerator 32 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 38.89% |
25.2%
13.7 pts better
|
Numerator 14 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
95.7%
4.4 pts worse
|
93.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 93.1% · Q3 90.6% · Q4 82.8% · 4Q avg 91.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
95.0%
1.7 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.2%
0.5 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.4% · Q3 4.7% · Q4 3.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
5.0%
4.1 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
4.9%
0.6 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 2.1% · Q3 4.0% · Q4 4.2% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.6% |
16.6%
4 pts better
|
19.6%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 8.5% · Q3 15.4% · Q4 16.0% · 4Q avg 12.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.1% |
16.7%
12.6 pts better
|
16.7%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 9.8% · Q3 4.3% · Q4 0.0% · 4Q avg 4.1% · 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 | 26.0% |
21.1%
4.9 pts worse
|
16.3%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.8% |
17.3%
2.5 pts worse
|
14.9%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 20.0% · Q3 12.2% · Q4 22.7% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
2.3%
2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
3.0%
1.3 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.6% · Q4 3.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.1% |
25.5%
2.6 pts worse
|
19.8%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 38.6% · Q3 21.4% · Q4 26.0% · 4Q avg 28.1% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
5.5%
1.4 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.6% · Q3 8.0% · Q4 8.9% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.2% |
86.8%
13.6 pts worse
|
81.7%
8.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 74.0% · Q3 64.8% · Q4 64.1% · 4Q avg 73.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.4% |
15.0%
3.4 pts worse
|
12.0%
6.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 18.3% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.3%
0.3 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.7% |
82.2%
22.5 pts worse
|
79.7%
20 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
22.7%
0.5 pts better
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 21.7% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-09 · Fire 2023-08-09
28 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-04-13 · Fire 2022-04-13
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-07
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-10-07
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-11-06
F · Potential for more than minimal harm
2024-10-07
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-10-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-26
E · Potential for more than minimal harm
2024-10-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-10-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-10-07
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-10-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-29
C · Minimal harm
2024-10-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-29
F · Potential for more than minimal harm
2023-08-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-18
F · Potential for more than minimal harm
2023-08-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-09
F · Potential for more than minimal harm
2023-08-09
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-09-09
E · Potential for more than minimal harm
2023-08-09
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-09-09
E · Potential for more than minimal harm
2023-08-09
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-09-09
E · Potential for more than minimal harm
2023-08-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-09
E · Potential for more than minimal harm
2023-08-09
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-09-09
E · Potential for more than minimal harm
2023-08-09
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-09-09
D · Potential for more than minimal harm
2023-08-09
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-09-09
D · Potential for more than minimal harm
2023-08-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-09
D · Potential for more than minimal harm
2023-08-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-09
D · Potential for more than minimal harm
2023-08-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-09
F · Potential for more than minimal harm
2022-04-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-05-11
F · Potential for more than minimal harm
2022-04-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-11
F · Potential for more than minimal harm
2022-04-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-05-11
F · Potential for more than minimal harm
2022-04-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-11
E · Potential for more than minimal harm
2022-04-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-05-11
D · Potential for more than minimal harm
2022-04-13
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-05-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-08
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2026-02-08
E · Potential for more than minimal harm
2026-01-08
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 2026-02-08
D · Potential for more than minimal harm
2026-01-08
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 2026-02-08
D · Potential for more than minimal harm
2026-01-08
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 2026-02-08
D · Potential for more than minimal harm
2025-12-04
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2026-01-04
D · Potential for more than minimal harm
2025-12-04
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2026-01-04
D · Potential for more than minimal harm
2025-12-04
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 2026-01-04
D · Potential for more than minimal harm
2025-12-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-01-04
D · Potential for more than minimal harm
2025-07-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-28
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-09-18
E · Potential for more than minimal harm
2025-03-20
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-20
E · Potential for more than minimal harm
2024-12-03
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 2024-12-20
D · Potential for more than minimal harm
2024-12-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-20
G · Actual harm
2024-10-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-05
G · Actual harm
2024-10-07
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 2024-12-20
F · Potential for more than minimal harm
2024-10-07
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 2024-11-05
E · Potential for more than minimal harm
2024-10-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-10-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-07
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-05
J · Immediate jeopardy
2024-07-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-21
F · Potential for more than minimal harm
2024-07-01
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-01
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-01
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-01
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-01
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-01
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-01
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-01
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-01
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-01
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-01
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-01
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-01
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 2024-08-06
D · Potential for more than minimal harm
2024-07-01
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-01
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-01
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-04-08
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-05-07
E · Potential for more than minimal harm
2023-08-09
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-09-09
D · Potential for more than minimal harm
2023-08-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-09
D · Potential for more than minimal harm
2023-08-09
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 2023-09-09
D · Potential for more than minimal harm
2023-08-09
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2023-09-09
D · Potential for more than minimal harm
2023-08-09
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-09-09
D · Potential for more than minimal harm
2023-08-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-09
G · Actual harm
2023-03-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-31
F · Potential for more than minimal harm
2022-04-13
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 2022-05-13
D · Potential for more than minimal harm
2022-04-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-05-13
Penalties and ownership
What sits behind the stars
$74,120
2024-10-07
Fine
Fine · fine $74,120
Fine
$0
2024-10-07
Payment Denial
Payment Denial · denial start 2024-11-06 · 51 days
51 day denial
$16,801
2024-07-01
Fine
Fine · fine $16,801
Fine
$0
2024-07-01
Payment Denial
Payment Denial · denial start 2024-07-30 · 22 days
22 day denial
Ownership
Nearby options
Other facilities in reach
#1
Amethyst Health Of Brown Deer
Milwaukee, WI
1-star overall rating with 1-star inspections with $282,090 in total fines with 25 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Bradley Estates Nursing And Rehab LLC
Milwaukee, WI
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $387,126 in total fines with 37 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Newcastle Place
Mequon, WI
3-star overall rating with 2-star inspections with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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