Cycle 1
Health 2026-01-07 · Fire 2026-01-07
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cedarburg, WI
Lasata Care Center
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
W76 N677 Wauwatosa Rd, Cedarburg, WI
(262) 377-5060
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
106
Certified beds
Average residents
80
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-07-01
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
0.84
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.49
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.43
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
5.08
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
5.19
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,605
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.80% · Performance 21.68% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.17
Baseline 6.58% · Performance 6.59% · Measure score 4.17 · Achievement 4.17 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.69
Baseline 4.93 hours · Performance 4.13 hours · Measure score 3.69 · Achievement 3.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.48% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 222 · Observed rate 11.71% · Lower 95% interval 8.8% |
| Discharge to community | 70.72% |
50.57%
20.1 pts better
|
Better than the National Rate · Eligible stays 206 · Observed rate 63.11% · Lower 95% interval 63.29% |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 120 · Denominator 120 |
| Falls with major injury | 1.67% |
0.77%
0.9 pts worse
|
Numerator 2 · Denominator 120 |
| Discharge self-care score | 55.66% |
53.69%
2 pts better
|
Numerator 59 · Denominator 106 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 53 · Denominator 106 |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 3 · Denominator 120 · Adjusted rate 3.12% |
| Healthcare-associated infections requiring hospitalization | 6.59% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 147 · Observed rate 5.44% · Lower 95% interval 4.06% |
| Staff COVID-19 vaccination coverage | 5.06% |
8.2%
3.1 pts worse
|
Numerator 9 · Denominator 178 |
| Staff flu vaccination coverage | 60.65% |
42%
18.6 pts better
|
Numerator 168 · Denominator 277 |
| Discharge function score | 61.32% |
56.45%
4.9 pts better
|
Numerator 65 · Denominator 106 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 79 · Denominator 79 |
| Resident COVID-19 vaccinations up to date | 48.08% |
25.2%
22.9 pts better
|
Numerator 25 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.2
1.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
95.7%
3.4 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.4% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
95.0%
3.4 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.2%
1.5 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.7% · Q4 3.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
5.0%
3.6 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 1.7% · Q4 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
4.9%
1.5 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 6.1% · Q3 6.7% · Q4 9.3% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.6% |
16.6%
8 pts worse
|
19.6%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 24.0% · Q3 26.1% · Q4 22.7% · 4Q avg 24.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.4% |
16.7%
2.3 pts better
|
16.7%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 14.0% · Q3 12.5% · Q4 17.1% · 4Q avg 14.4% · 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 | 11.4% |
21.1%
9.7 pts better
|
16.3%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.5% |
17.3%
1.2 pts worse
|
14.9%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 16.3% · Q3 14.3% · Q4 17.5% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
2.3%
0.1 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 1.7% · Q3 0.0% · Q4 2.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
3.0%
0.9 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 3.6% · Q3 3.4% · Q4 0.0% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.3% |
25.5%
9.8 pts worse
|
19.8%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 37.1% · Q3 27.9% · Q4 45.1% · 4Q avg 35.3% |
| 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 3.2% · Q2 2.2% · Q3 5.4% · Q4 2.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.6% |
86.8%
5.2 pts worse
|
81.7%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 80.6% · Q2 78.8% · Q3 83.4% · Q4 83.2% · 4Q avg 81.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
15.0%
5.5 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 8.3% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.3% |
82.2%
1.1 pts better
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.1% |
22.7%
0.4 pts worse
|
23.9%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 18.3% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-11 · Fire 2024-09-11
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2023-06-21 · Fire 2023-06-21
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-20
E · Potential for more than minimal harm
2026-01-07
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 2026-01-08
E · Potential for more than minimal harm
2026-01-07
K321 · Smoke Deficiencies
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 2026-01-07
E · Potential for more than minimal harm
2026-01-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-07
E · Potential for more than minimal harm
2026-01-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-01-09
F · Potential for more than minimal harm
2024-09-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-26
F · Potential for more than minimal harm
2024-09-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-09-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-09-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-09-11
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-09-11
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-09-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-09-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-09-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-09-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-19
D · Potential for more than minimal harm
2024-09-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-31
C · Minimal harm
2024-09-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-20
F · Potential for more than minimal harm
2023-06-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-20
F · Potential for more than minimal harm
2023-06-21
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-06-23
F · Potential for more than minimal harm
2023-06-21
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-06-23
F · Potential for more than minimal harm
2023-06-21
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-07-20
F · Potential for more than minimal harm
2023-06-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-06-21
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-06-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-06-21
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 2023-07-21
E · Potential for more than minimal harm
2023-06-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-21
K321 · Smoke Deficiencies
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 2023-07-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-07
D · Potential for more than minimal harm
2026-01-07
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 2026-02-07
D · Potential for more than minimal harm
2026-01-07
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 2026-02-07
C · Minimal harm
2024-09-11
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-04-08
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 2024-05-01
D · Potential for more than minimal harm
2024-04-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-08
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 2024-05-01
D · Potential for more than minimal harm
2023-06-21
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 2023-07-13
D · Potential for more than minimal harm
2023-06-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-13
D · Potential for more than minimal harm
2023-06-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-21
Penalties and ownership
What sits behind the stars
Ownership
County Of Ozaukee
5% Or Greater Direct Ownership Interest · Organization
Smith, Barton
Corporate Director · Individual
Smith, Barton
W-2 Managing Employee · Individual
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