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
Staffing
Hours and turnover
RN hours / resident day
0.88
Registered nurse staffing
LPN hours / resident day
0.92
Licensed practical nurse staffing
Aide hours / resident day
2.30
Nurse aide staffing
Weekend hours
3.55
Weekend nurse staffing
RN turnover
14%
Annual RN turnover
Total nurse turnover
34%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
#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
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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