5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Milwaukee, WI
4-star overall rating with 3-star inspections with $8,959 in total fines with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1414 N Prospect Ave, Milwaukee, WI
(414) 276-2627
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
102
Certified beds
Average residents
76
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-03-13
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
RN hours / resident day
0.65
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.39
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.79
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.82
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.04
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.54
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.45
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
0.69
CMS adjusted RN staffing hours
Adjusted total hours
5.12
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
3,100
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9993
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.46
Baseline 20.74% · Performance 20.29% · Measure score 2.46 · Achievement 2.46 · Improvement 0.71
Healthcare-associated infections
3.56
Baseline 5.00% · Performance 6.77% · Measure score 3.56 · Achievement 3.56 · Improvement 0
Total nurse turnover
5.46
Baseline 39.33% · Performance 41.35% · Measure score 5.46 · Achievement 5.46 · Improvement 0
Adjusted total nurse staffing
6.93
Baseline 4.48 hours · Performance 5.05 hours · Measure score 6.93 · Achievement 6.93 · Improvement 3.87
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.09% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 119 · Observed rate 13.45% · Lower 95% interval 9.03% |
| Discharge to community | 60.52% |
50.57%
10 pts better
|
Better than the National Rate · Eligible stays 118 · Observed rate 52.54% · Lower 95% interval 52.48% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 68 · Denominator 68 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 68 |
| Discharge self-care score | 72.41% |
53.69%
18.7 pts better
|
Numerator 42 · Denominator 58 |
| Discharge mobility score | 63.79% |
50.94%
12.9 pts better
|
Numerator 37 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 5.88% |
2.29%
3.6 pts worse
|
Numerator 4 · Denominator 68 · Adjusted rate 5.95% |
| Healthcare-associated infections requiring hospitalization | 6.77% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 5.71% · Lower 95% interval 3.83% |
| Staff COVID-19 vaccination coverage | 1.48% |
8.2%
6.7 pts worse
|
Numerator 3 · Denominator 203 |
| Staff flu vaccination coverage | 76.58% |
42%
34.6 pts better
|
Numerator 170 · Denominator 222 |
| Discharge function score | 65.52% |
56.45%
9.1 pts better
|
Numerator 38 · Denominator 58 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 45 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 40.63% |
25.2%
15.4 pts better
|
Numerator 13 · Denominator 32 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.9% |
95.7%
13.8 pts worse
|
93.4%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 83.1% · Q3 79.7% · Q4 74.2% · 4Q avg 81.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.8% |
95.0%
2.2 pts worse
|
95.5%
2.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.5% |
3.2%
4.3 pts worse
|
3.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 4.6% · Q3 9.4% · Q4 8.1% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
5.0%
2 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.9% · Q3 2.1% · Q4 5.7% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
4.9%
1.7 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 6.8% · Q3 7.0% · Q4 3.6% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.7% |
16.6%
4.1 pts worse
|
19.6%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 18.3% · Q3 21.1% · Q4 21.8% · 4Q avg 20.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.8% |
16.7%
10.9 pts better
|
16.7%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.5% · Q3 4.0% · Q4 8.2% · 4Q avg 5.8% · 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 | 17.2% |
21.1%
3.9 pts better
|
16.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
17.3%
1.5 pts better
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 12.3% · Q3 11.3% · Q4 30.2% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
2.3%
0.9 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.7% · Q3 3.0% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
3.0%
0.2 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 6.2% · Q3 3.1% · Q4 1.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
25.5%
2.8 pts better
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 27.8% · Q3 24.2% · Q4 19.0% · 4Q avg 22.7% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.5%
2.2 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.2% · Q3 4.2% · Q4 5.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.2% |
86.8%
11.6 pts worse
|
81.7%
6.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.1% · Q2 70.8% · Q3 75.8% · Q4 83.2% · 4Q avg 75.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.3% |
15.0%
0.3 pts worse
|
12.0%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 13.8% · Expected 10.1% · 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 | 61.0% |
82.2%
21.2 pts worse
|
79.7%
18.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 61.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
22.7%
1 pts worse
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 19.0% · Expected 19.1% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-01-28
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-02-13
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-14
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-23
Fire Safety
Use approved construction type or materials.
Corrected 2027-01-01
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-02-11
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-17
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-14
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-22
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-11-21
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-11-22
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-21
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-26
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-26
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-08-26
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-08-26
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2022-08-26
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-08-26
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-08-26
Inspection history
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-13
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-13
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-21
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 2025-02-10
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 2025-02-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-30
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-22
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-22
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-22
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-11-22
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-22
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 2023-11-22
Penalties and ownership
Fine · fine $8,959
Fine
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Nearby options
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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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
Milwaukee, WI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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