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

Compare this facility

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

Staffing

Hours and turnover

RN hours / resident day

0.61

Registered nurse staffing

LPN hours / resident day

0.53

Licensed practical nurse staffing

Aide hours / resident day

1.72

Nurse aide staffing

Weekend hours

2.63

Weekend nurse staffing

RN turnover

0%

Annual RN turnover

Total nurse turnover

0%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

Survey summary

Recent inspection cycles

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)

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

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