Cycle 1
Health 2025-06-10 · Fire 2025-06-10
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Wauwatosa, WI
Lutheran Home
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
7500 W North Ave, Wauwatosa, WI
(414) 258-6170
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
Facility snapshot
Beds
160
Certified beds
Average residents
129
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-09-01
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
0.88
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.11
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.55
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
4.32
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,926
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.97
Composite VBP score used to determine payment impact.
Payment multiplier
1.0076
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.34
Baseline 16.91% · Performance 19.88% · Measure score 3.34 · Achievement 3.34 · Improvement 0
Healthcare-associated infections
6
Baseline 4.76% · Performance 6.04% · Measure score 6 · Achievement 6 · Improvement 0
Total nurse turnover
7.97
Baseline 27.22% · Performance 31.10% · Measure score 7.97 · Achievement 7.97 · Improvement 0
Adjusted total nurse staffing
3.88
Baseline 4.03 hours · Performance 4.18 hours · Measure score 3.88 · Achievement 3.88 · Improvement 0.36
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.17% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 235 · Observed rate 11.91% · Lower 95% interval 8.95% |
| Discharge to community | 58.14% |
50.57%
7.6 pts better
|
Better than the National Rate · Eligible stays 242 · Observed rate 53.72% · Lower 95% interval 51.19% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.09% |
95.27%
1.8 pts better
|
Numerator 100 · Denominator 103 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 103 |
| Discharge self-care score | 48.28% |
53.69%
5.4 pts worse
|
Numerator 42 · Denominator 87 |
| Discharge mobility score | 47.13% |
50.94%
3.8 pts worse
|
Numerator 41 · Denominator 87 |
| Pressure ulcers or injuries, new or worsened | 5.83% |
2.29%
3.5 pts worse
|
Numerator 6 · Denominator 103 · Adjusted rate 6.38% |
| Healthcare-associated infections requiring hospitalization | 6.04% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 129 · Observed rate 3.88% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | 9.55% |
8.2%
1.4 pts better
|
Numerator 34 · Denominator 356 |
| Staff flu vaccination coverage | 90.02% |
42%
48 pts better
|
Numerator 559 · Denominator 621 |
| Discharge function score | 60.92% |
56.45%
4.5 pts better
|
Numerator 53 · Denominator 87 |
| Transfer of health information to provider | 88.46% |
95.95%
7.5 pts worse
|
Numerator 23 · Denominator 26 |
| Transfer of health information to patient | 97.1% |
96.28%
0.8 pts better
|
Numerator 67 · Denominator 69 |
| Resident COVID-19 vaccinations up to date | 74.51% |
25.2%
49.3 pts better
|
Numerator 38 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
2.2
2.2 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
95.7%
3.8 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 99.0% · Q4 100.0% · 4Q avg 99.5% |
| 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 | 1.3% |
3.2%
1.9 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.1% · Q3 0.0% · Q4 2.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.1% |
5.0%
2.9 pts better
|
11.4%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.1% · Q3 1.1% · Q4 3.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
4.9%
1.3 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.4% · Q3 3.9% · Q4 9.9% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.3% |
16.6%
6.3 pts better
|
19.6%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 11.4% · Q3 7.7% · Q4 10.6% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
16.7%
1.5 pts better
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 16.4% · Q3 14.5% · Q4 15.1% · 4Q avg 15.2% · 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% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.1% |
21.1%
3 pts worse
|
16.3%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 26.9% · Q3 15.4% · Q4 18.8% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.4% |
17.3%
5.9 pts better
|
14.9%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 17.3% · Q3 9.7% · Q4 8.9% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
2.3%
0.5 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.5% · Q3 2.9% · Q4 1.8% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.7% |
3.0%
1.7 pts worse
|
1.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.4% · Q3 3.1% · Q4 5.2% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.4% |
25.5%
11.9 pts worse
|
19.8%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 46.6% · Q3 29.3% · Q4 37.2% · 4Q avg 37.4% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
5.5%
1.9 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 7.0% · Q3 6.8% · Q4 7.7% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
86.8%
11.3 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 97.5% · Q3 98.7% · Q4 99.2% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
15.0%
4.4 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 10.1% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
82.2%
11.6 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.9% |
22.7%
7.2 pts worse
|
23.9%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.9% · Observed 25.7% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-14 · Fire 2024-03-14
8 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-12-13 · Fire 2022-12-13
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-06-10
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 2025-07-10
D · Potential for more than minimal harm
2025-06-10
K233 · Egress Deficiencies
Fire Safety
Install resident room doors of proper design and width.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-10
E · Potential for more than minimal harm
2024-03-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-03-14
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 2024-03-27
D · Potential for more than minimal harm
2024-03-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-03-14
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-03-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-27
D · Potential for more than minimal harm
2022-12-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-12-13
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-01-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-10
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-06-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-06-10
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 2025-07-10
E · Potential for more than minimal harm
2025-06-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-10
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 2025-07-10
D · Potential for more than minimal harm
2025-06-10
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 2025-07-10
D · Potential for more than minimal harm
2025-06-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-10
F761 · Pharmacy Service Deficiencies
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 2025-07-10
B · Minimal harm
2025-06-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-02-04
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 2025-03-04
F · Potential for more than minimal harm
2024-03-14
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 2024-04-14
E · Potential for more than minimal harm
2024-03-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-04-14
D · Potential for more than minimal harm
2024-03-14
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 2024-04-14
D · Potential for more than minimal harm
2024-03-14
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 2024-04-14
D · Potential for more than minimal harm
2024-03-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-14
D · Potential for more than minimal harm
2024-03-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-14
D · Potential for more than minimal harm
2024-03-14
F761 · Pharmacy Service Deficiencies
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 2024-04-14
G · Actual harm
2023-10-19
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 2023-11-17
D · Potential for more than minimal harm
2023-10-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-11-17
Penalties and ownership
What sits behind the stars
Ownership
Bukowy, Elizabeth
Operational/Managerial Control · Individual
Cavers, Kathryn
Operational/Managerial Control · Individual
Cavers, Kathryn
Corporate Officer · Individual
Clausen, Henrik
Operational/Managerial Control · Individual
Clausen, Henrik
Corporate Officer · Individual
Denor, Jim
Corporate Director · Individual
Ehn, Diane
Corporate Director · Individual
Ehn, Diane
Corporate Officer · Individual
Hodan, Mike
Corporate Director · Individual
Kebbekus, Ben
Corporate Director · Individual
Kriete, Lindsey
Corporate Director · Individual
Mueller, Gary
Corporate Director · Individual
Pedersen, Harriet
Corporate Director · Individual
Pingel, Lindsay
Operational/Managerial Control · Individual
Pingel, Lindsay
Corporate Director · Individual
Raasch, Randy
Corporate Director · Individual
Reardon, Tim
Corporate Director · Individual
Rosenberg, Paul
Corporate Director · Individual
Sandstrom, David
Corporate Director · Individual
Sandstrom, David
Corporate Officer · Individual
Surma, Kristina
Corporate Director · Individual
Surma, Kristina
Corporate Officer · Individual
Swartz Bartlett, Carey
Operational/Managerial Control · Individual
Tettenborn, Jayne
Operational/Managerial Control · Individual
Triska Wiemer, Katie
Corporate Director · Individual
Nearby options
Other facilities in reach
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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
St Camillus Health Center
Wauwatosa, WI
3-star overall rating with 2-star inspections with $90,430 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Milwaukee Health and Rehab
Milwaukee, WI
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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