5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
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
2115 E Woodstock Pl, Milwaukee, WI
(414) 271-1020
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
145
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eden Senior Care
Operator or chain grouping
Approved since
1982-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
18 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
RN hours / resident day
1.07
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
3.09
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
12,640
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.58
Baseline 18.63% · Performance 20.70% · Measure score 1.58 · Achievement 1.58 · Improvement 0
Healthcare-associated infections
1.78
Baseline 6.34% · Performance 7.30% · Measure score 1.78 · Achievement 1.78 · Improvement 0
Total nurse turnover
1.16
Baseline 55.29% · Performance 58.93% · Measure score 1.16 · Achievement 1.16 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.86 hours · Performance 2.95 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.64% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 17.24% · Lower 95% interval 8.33% |
| Discharge to community | 34.64% |
50.57%
15.9 pts worse
|
Worse than the National Rate · Eligible stays 51 · Observed rate 19.61% · Lower 95% interval 21.59% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 92.31% |
95.27%
3 pts worse
|
Numerator 36 · Denominator 39 |
| Falls with major injury | 2.56% |
0.77%
1.8 pts worse
|
Numerator 1 · Denominator 39 |
| Discharge self-care score | 43.48% |
53.69%
10.2 pts worse
|
Numerator 10 · Denominator 23 |
| Discharge mobility score | 39.13% |
50.94%
11.8 pts worse
|
Numerator 9 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 2.56% |
2.29%
0.3 pts worse
|
Numerator 1 · Denominator 39 · Adjusted rate 1.7% |
| Healthcare-associated infections requiring hospitalization | 7.3% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 12.2% · Lower 95% interval 4.49% |
| Staff COVID-19 vaccination coverage | 6.94% |
8.2%
1.3 pts worse
|
Numerator 10 · Denominator 144 |
| Staff flu vaccination coverage | 34.97% |
42%
7 pts worse
|
Numerator 64 · Denominator 183 |
| Discharge function score | 39.13% |
56.45%
17.3 pts worse
|
Numerator 9 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28.57% |
25.2%
3.4 pts better
|
Numerator 6 · Denominator 21 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 3.5 · Expected 5.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 3.3 · Expected 3.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 79.2% |
95.7%
16.5 pts worse
|
93.4%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.9% · Q2 82.9% · Q3 78.7% · Q4 72.4% · 4Q avg 79.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.0% |
95.0%
14 pts worse
|
95.5%
14.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 81.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 2.7% · Q4 3.9% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
5.0%
1.7 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.3% · Q3 3.2% · Q4 1.7% · 4Q avg 3.3% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
4.9%
1.6 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 10.1% · Q3 4.5% · Q4 2.8% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.2% |
16.6%
4.4 pts better
|
19.6%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 14.3% · Q3 13.6% · Q4 8.5% · 4Q avg 12.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
16.7%
4.6 pts better
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 10.6% · Q3 9.8% · Q4 13.5% · 4Q avg 12.1% · 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 | 15.3% |
21.1%
5.8 pts better
|
16.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.3% |
17.3%
10 pts better
|
14.9%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 0.0% · Q3 10.6% · Q4 8.0% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
3.0%
1.7 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 1.4% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.7% |
25.5%
0.2 pts worse
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 19.2% · Q3 21.4% · Q4 30.6% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.5%
0.9 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 7.2% · Q3 6.6% · Q4 1.4% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 32.9% |
86.8%
53.9 pts worse
|
81.7%
48.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 34.0% · Q3 40.7% · Q4 29.0% · 4Q avg 32.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
15.0%
4.6 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 13.5% · Expected 14.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.0% |
82.2%
42.2 pts worse
|
79.7%
39.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 40.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.2% |
22.7%
5.5 pts worse
|
23.9%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.2% · Observed 37.8% · Expected 32.0% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Pharmacy Service (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Quality of Life and Care (9 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-18
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-18
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-18
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 2024-11-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-18
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-18
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-18
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-12-28
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-28
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 2023-10-31
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-10-13
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 2023-10-13
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-13
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-10-13
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-13
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-06-24
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-24
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-06-24
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 2022-06-24
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-06-24
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-24
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-06-24
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-06-24
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-06-24
Fire Safety
Install resident room doors of proper design and width.
Corrected 2022-06-24
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 2022-06-24
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-06-24
Inspection history
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-03-19
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2025-03-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-18
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-18
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-18
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-11-18
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-18
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-29
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-29
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-05
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-02-22
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-05
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-02
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 2024-01-02
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-10-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-17
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 2023-10-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-17
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-17
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-10-17
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-06-24
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 2022-06-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-24
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-06-24
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-24
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-06-24
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-06-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-24
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-06-24
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-06-24
Health
Post nurse staffing information every day.
Corrected 2022-06-24
Penalties and ownership
Fine · fine $59,813
Fine
Payment Denial · denial start 2024-02-23 · 11 days
11 day denial
Fine · fine $78,621
Fine
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
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