Cycle 1
Health 2024-09-10 · Fire 2024-09-10
18 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Milwaukee, WI
Luther Manor
1-star overall rating with 1-star inspections with $170,666 in total fines with 18 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
4545 N 92nd St, Milwaukee, WI
(414) 464-3880
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
95
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-05-01
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
0.69
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.23
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.89
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.81
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.92
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.33
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.63
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
61%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,840
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.62
Composite VBP score used to determine payment impact.
Payment multiplier
1.0084
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.56
Baseline 17.11% · Performance 19.32% · Measure score 4.56 · Achievement 4.56 · Improvement 0
Healthcare-associated infections
9.36
Baseline 4.74% · Performance 5.04% · Measure score 9.36 · Achievement 9.36 · Improvement 0
Total nurse turnover
1.82
Baseline 55.26% · Performance 56.25% · Measure score 1.82 · Achievement 1.82 · Improvement 0
Adjusted total nurse staffing
5.72
Baseline 4.24 hours · Performance 4.70 hours · Measure score 5.72 · Achievement 5.72 · Improvement 2.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.5% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 165 · Observed rate 10.91% · Lower 95% interval 7.42% |
| Discharge to community | 48.47% |
50.57%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 157 · Observed rate 40.76% · Lower 95% interval 40.31% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.1% |
95.27%
1.8 pts better
|
Numerator 67 · Denominator 69 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 69 |
| Discharge self-care score | 49.06% |
53.69%
4.6 pts worse
|
Numerator 26 · Denominator 53 |
| Discharge mobility score | 41.51% |
50.94%
9.4 pts worse
|
Numerator 22 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 1.45% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 69 · Adjusted rate 1.3% |
| Healthcare-associated infections requiring hospitalization | 5.04% |
7.12%
2.1 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 0% · Lower 95% interval 2.7% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 50.94% |
56.45%
5.5 pts worse
|
Numerator 27 · Denominator 53 |
| 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 | 94.87% |
96.28%
1.4 pts worse
|
Numerator 37 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 17 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
95.7%
4 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
95.0%
2.5 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.2%
0.4 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.2% · Q3 5.1% · Q4 3.8% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
5.0%
3.1 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 1.4% · Q4 2.9% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
4.9%
1.7 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.8% · Q3 3.6% · Q4 3.7% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.4% |
16.6%
5.2 pts better
|
19.6%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 9.4% · Q3 10.7% · Q4 14.8% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.3% |
16.7%
1.6 pts worse
|
16.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 17.8% · Q3 14.0% · Q4 17.8% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.0% |
0.1%
0.9 pts worse
|
0.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.3% · Q4 1.2% · 4Q avg 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 33.7% |
21.1%
12.6 pts worse
|
16.3%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.8% |
17.3%
1.5 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 34.0% · Q3 13.0% · Q4 18.4% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
2.3%
0.6 pts better
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.0% · Q3 1.6% · Q4 1.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.0% |
3.0%
1 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.4% · Q3 5.1% · Q4 5.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.8% |
25.5%
8.3 pts worse
|
19.8%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.9% · Q2 33.5% · Q3 37.4% · Q4 27.7% · 4Q avg 33.8% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
5.5%
0.4 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.9% · Q3 5.3% · Q4 6.3% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
86.8%
8.3 pts better
|
81.7%
13.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 96.8% · Q3 95.4% · Q4 94.6% · 4Q avg 95.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
15.0%
3.8 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 10.9% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
82.2%
14.7 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
22.7%
1.4 pts worse
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 23.6% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-27 · Fire 2023-07-27
21 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2022-04-04 · Fire 2022-04-04
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-10
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-10-07
F · Potential for more than minimal harm
2024-09-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-09-25
F · Potential for more than minimal harm
2024-09-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-09-10
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-09-10
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 2024-10-14
E · Potential for more than minimal harm
2024-09-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-09-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-09-10
K791 · Miscellaneous Deficiencies
Fire Safety
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-09-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-09-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-09-10
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-09-17
F · Potential for more than minimal harm
2023-07-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-23
F · Potential for more than minimal harm
2023-07-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-23
F · Potential for more than minimal harm
2023-07-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-07-27
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-07-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-27
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-27
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-07-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-25
C · Minimal harm
2023-07-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-25
F · Potential for more than minimal harm
2022-04-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-04-14
F · Potential for more than minimal harm
2022-04-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-04-01
F · Potential for more than minimal harm
2022-04-04
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-04-22
F · Potential for more than minimal harm
2022-04-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-04-01
F · Potential for more than minimal harm
2022-04-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-14
F · Potential for more than minimal harm
2022-04-04
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-04-14
F · Potential for more than minimal harm
2022-04-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-04-14
E · Potential for more than minimal harm
2022-04-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-03-29
Inspection history
Recent health citations
G · Actual harm
2026-01-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Not marked corrected
D · Potential for more than minimal harm
2025-07-29
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 2025-08-21
D · Potential for more than minimal harm
2025-05-13
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 2025-05-31
D · Potential for more than minimal harm
2025-03-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-27
D · Potential for more than minimal harm
2024-10-31
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-10-31
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 2024-11-19
D · Potential for more than minimal harm
2024-10-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-31
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-10-31
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-31
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-31
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-10-31
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 2024-12-03
D · Potential for more than minimal harm
2024-10-31
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 2024-11-29
J · Immediate jeopardy
2024-09-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-08
J · Immediate jeopardy
2024-09-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-20
F · Potential for more than minimal harm
2024-09-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-09-10
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 2024-09-30
E · Potential for more than minimal harm
2024-09-10
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 2024-09-15
E · Potential for more than minimal harm
2024-09-10
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 2024-09-20
D · Potential for more than minimal harm
2024-09-10
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 2024-11-19
D · Potential for more than minimal harm
2024-09-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-10
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 2024-10-11
D · Potential for more than minimal harm
2024-09-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-09-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-10
F756 · Pharmacy Service Deficiencies
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 2024-09-19
D · Potential for more than minimal harm
2024-09-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-10
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 2024-09-15
J · Immediate jeopardy
2024-06-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-03
G · Actual harm
2024-06-11
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 2024-07-03
D · Potential for more than minimal harm
2024-06-11
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 2024-07-03
D · Potential for more than minimal harm
2024-06-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-06-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-03
G · Actual harm
2024-02-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-14
G · Actual harm
2024-02-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-14
E · Potential for more than minimal harm
2024-02-01
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 2024-03-04
D · Potential for more than minimal harm
2024-02-01
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 2024-02-06
D · Potential for more than minimal harm
2024-02-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-01
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 2024-03-04
E · Potential for more than minimal harm
2023-07-27
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 2023-08-25
D · Potential for more than minimal harm
2023-07-27
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 2023-08-25
D · Potential for more than minimal harm
2023-07-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-27
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 2023-08-23
D · Potential for more than minimal harm
2023-07-27
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 2023-08-23
D · Potential for more than minimal harm
2023-07-27
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-04-05
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 2023-05-05
F · Potential for more than minimal harm
2022-04-04
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 2022-04-14
D · Potential for more than minimal harm
2022-04-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-04-15
Penalties and ownership
What sits behind the stars
$103,705
2024-09-10
Fine
Fine · fine $103,705
Fine
$0
2024-09-10
Payment Denial
Payment Denial · denial start 2024-10-11 · 53 days
53 day denial
$34,468
2024-06-11
Fine
Fine · fine $34,468
Fine
$25,454
2024-02-01
Fine
Fine · fine $25,454
Fine
$0
2024-02-01
Payment Denial
Payment Denial · denial start 2024-02-29 · 14 days
14 day denial
$2,117
2023-08-14
Fine
Fine · fine $2,117
Fine
$1,748
2023-08-07
Fine
Fine · fine $1,748
Fine
$3,174
2023-07-17
Fine
Fine · fine $3,174
Fine
Ownership
Chedid, Stephanie
Corporate Officer · Individual
Cooper, Delila
Operational/Managerial Control · Individual
Gibbs, Karen
Operational/Managerial Control · Individual
Hansen, Patrick
Operational/Managerial Control · Individual
Hansen, Patrick
Corporate Officer · Individual
Jung, Kim
Operational/Managerial Control · Individual
Keup, Arthur
Corporate Officer · Individual
Select Rehabilitation, LLC
Operational/Managerial Control · Organization
Sodexo America, LLC
Operational/Managerial Control · Organization
United Lutheran Program For The Aging, Inc
5% Or Greater Direct Ownership Interest · Organization
United Lutheran Program For The Aging, Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
St Anne's Salvatorian Campus
Milwaukee, WI
2-star overall rating with 1-star inspections with $326,060 in total fines with 26 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Lutheran Home
Wauwatosa, WI
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Congregational Home, Inc
Brookfield, WI
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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