Cycle 1
Health 2024-11-27 · Fire 2024-11-27
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Milwaukee, WI
Eastcastle Pl Bradford Ter Conv Ctr
5-star overall rating with 5-star inspections with $99,452 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2505 E Bradford Ave, Milwaukee, WI
(414) 963-6151
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
40
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.95
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.22
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.16
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.94
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.59
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.96
CMS adjusted RN staffing hours
Adjusted total hours
5.20
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,650
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.01
Composite VBP score used to determine payment impact.
Payment multiplier
1.0100
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.14
Baseline 18.40% · Performance 17.66% · Measure score 8.14 · Achievement 8.14 · Improvement 4.90
Healthcare-associated infections
5.92
Baseline 5.37% · Performance 6.07% · Measure score 5.92 · Achievement 5.92 · Improvement 0
Total nurse turnover
1.65
Performance 56.92% · Measure score 1.65 · Achievement 1.65 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.30
Baseline 5.10 hours · Performance 4.87 hours · Measure score 6.30 · Achievement 6.30 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.15% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 139 · Observed rate 7.19% · Lower 95% interval 7.13% |
| Discharge to community | 57.98% |
50.57%
7.4 pts better
|
Better than the National Rate · Eligible stays 136 · Observed rate 58.82% · Lower 95% interval 52.39% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 74 · Denominator 74 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 74 |
| Discharge self-care score | 63.49% |
53.69%
9.8 pts better
|
Numerator 40 · Denominator 63 |
| Discharge mobility score | 49.21% |
50.94%
1.7 pts worse
|
Numerator 31 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 1.35% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 74 · Adjusted rate 2.08% |
| Healthcare-associated infections requiring hospitalization | 6.07% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 2.63% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 188 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 202 · Denominator 202 |
| Discharge function score | 63.49% |
56.45%
7 pts better
|
Numerator 40 · Denominator 63 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 53 · Denominator 53 |
| Resident COVID-19 vaccinations up to date | 57.89% |
25.2%
32.7 pts better
|
Numerator 22 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
95.7%
3.2 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 95.2% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
5.0%
2.4 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.5% · Q3 0.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.9%
4.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.4% |
16.6%
5.8 pts worse
|
19.6%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 20.0% · 4Q avg 22.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.2% |
16.7%
12.5 pts better
|
16.7%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.2% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.9% |
17.3%
10.4 pts better
|
14.9%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
2.3%
0.7 pts better
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.0%
3 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.9% |
25.5%
6.4 pts worse
|
19.8%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 22.7% · 4Q avg 31.9% |
| Percentage of long-stay residents with pressure ulcers | 11.6% |
5.5%
6.1 pts worse
|
5.1%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 14.3% · Q3 8.2% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.8%
13.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.1% |
15.0%
9.1 pts worse
|
12.0%
12.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 21.6% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.3%
1.1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
82.2%
17.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.0% |
22.7%
3.7 pts better
|
23.9%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 14.8% · Expected 18.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-31 · Fire 2023-08-31
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-05-19 · Fire 2022-05-19
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-27
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-11-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-30
C · Minimal harm
2024-11-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-30
F · Potential for more than minimal harm
2022-05-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-06-10
F · Potential for more than minimal harm
2022-05-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-24
E · Potential for more than minimal harm
2022-05-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-06-14
E · Potential for more than minimal harm
2022-05-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-05-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-06-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-15
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 2025-08-14
D · Potential for more than minimal harm
2024-11-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-27
G · Actual harm
2022-05-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-06-17
F · Potential for more than minimal harm
2022-05-19
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-05-19
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-19
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-19
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 2022-06-17
D · Potential for more than minimal harm
2022-05-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-19
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 2022-06-17
D · Potential for more than minimal harm
2022-05-19
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 2022-06-17
D · Potential for more than minimal harm
2022-05-19
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-19
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 2022-06-17
D · Potential for more than minimal harm
2022-05-19
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 2022-06-17
D · Potential for more than minimal harm
2022-05-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-19
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-06-17
Penalties and ownership
What sits behind the stars
$4,938
2024-02-20
Fine
Fine · fine $4,938
Fine
$4,938
2024-02-12
Fine
Fine · fine $4,938
Fine
$14,814
2024-01-22
Fine
Fine · fine $14,814
Fine
$4,938
2024-01-08
Fine
Fine · fine $4,938
Fine
$4,587
2024-01-02
Fine
Fine · fine $4,587
Fine
$13,762
2023-12-11
Fine
Fine · fine $13,762
Fine
$4,587
2023-11-20
Fine
Fine · fine $4,587
Fine
$4,587
2023-11-13
Fine
Fine · fine $4,587
Fine
$4,587
2023-11-06
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-30
Fine
Fine · fine $4,587
Fine
$4,545
2023-10-23
Fine
Fine · fine $4,545
Fine
$4,587
2023-10-17
Fine
Fine · fine $4,587
Fine
$4,235
2023-10-10
Fine
Fine · fine $4,235
Fine
$10,586
2023-09-18
Fine
Fine · fine $10,586
Fine
$2,823
2023-08-14
Fine
Fine · fine $2,823
Fine
$6,351
2023-07-24
Fine
Fine · fine $6,351
Fine
Ownership
Becker, Laurie
Corporate Director · Individual
Becker, Laurie
Corporate Officer · Individual
Beer, Alexander
Corporate Director · Individual
Bissonnette, Julie
Corporate Director · Individual
Bissonnette, Julie
Corporate Officer · Individual
Bremer Bank National Association
5% Or Greater Security Interest · Organization
Bremer Bank National Association
5% Or Greater Mortgage Interest · Organization
Harris, Brooke
Operational/Managerial Control · Individual
Jeglum, Bonnie
Corporate Officer · Individual
Lange, George
Corporate Director · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
Marek, George
Corporate Director · Individual
Marek, George
Corporate Officer · Individual
Normington, Havilah
Corporate Director · Individual
O'donnell, Nancy
Corporate Director · Individual
O'donnell, Nancy
Corporate Officer · Individual
Old National Bank
5% Or Greater Security Interest · Organization
Old National Bank
5% Or Greater Mortgage Interest · Organization
Ramanujam, Sandeep
Operational/Managerial Control · Individual
Reilly, Dennis
Corporate Director · Individual
Rodgers, Karen
Corporate Director · Individual
Sitzberger, Bradley
Operational/Managerial Control · Individual
Tice, Barbara
Corporate Director · Individual
Tillmar, Katherine
Corporate Director · Individual
Williamson, Joanne
Corporate Director · Individual
Williamson, Joanne
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Milwaukee Catholic Home
Milwaukee, WI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Edenbrook Lakeside
Milwaukee, WI
2-star overall rating with 2-star inspections with $138,434 in total fines with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Saint Johns On The Lake
Milwaukee, WI
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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