Cycle 1
Health 2025-06-03 · Fire 2025-06-03
3 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Milwaukee, WI
Milwaukee Catholic Home
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2330 N Prospect Ave, Milwaukee, WI
(414) 220-4610
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
107
Certified beds
Average residents
98
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-08-05
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
1.12
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
4.06
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.94
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.88
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
5.49
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.74
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
1.30
CMS adjusted RN staffing hours
Adjusted total hours
6.89
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
886
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.49
Composite VBP score used to determine payment impact.
Payment multiplier
1.0174
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.77
Baseline 20.16% · Performance 19.69% · Measure score 3.77 · Achievement 3.77 · Improvement 1.02
Healthcare-associated infections
4.60
Baseline 7.14% · Performance 6.46% · Measure score 4.60 · Achievement 4.60 · Improvement 2.67
Total nurse turnover
6.63
Baseline 41.35% · Performance 36.60% · Measure score 6.63 · Achievement 6.63 · Improvement 2.38
Adjusted total nurse staffing
10
Baseline 4.91 hours · Performance 5.87 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.81% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 206 · Observed rate 8.25% · Lower 95% interval 7.62% |
| Discharge to community | 63.14% |
50.57%
12.6 pts better
|
Better than the National Rate · Eligible stays 207 · Observed rate 59.42% · Lower 95% interval 56.17% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 95.92% |
95.27%
0.7 pts better
|
Numerator 94 · Denominator 98 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 2 · Denominator 98 |
| Discharge self-care score | 48.31% |
53.69%
5.4 pts worse
|
Numerator 43 · Denominator 89 |
| Discharge mobility score | 41.57% |
50.94%
9.4 pts worse
|
Numerator 37 · Denominator 89 |
| Pressure ulcers or injuries, new or worsened | 3.06% |
2.29%
0.8 pts worse
|
Numerator 3 · Denominator 98 · Adjusted rate 3.53% |
| Healthcare-associated infections requiring hospitalization | 6.46% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 4.51% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 7.37% |
8.2%
0.8 pts worse
|
Numerator 28 · Denominator 380 |
| Staff flu vaccination coverage | 91.72% |
42%
49.7 pts better
|
Numerator 266 · Denominator 290 |
| Discharge function score | 67.42% |
56.45%
11 pts better
|
Numerator 60 · Denominator 89 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 46 · Denominator 46 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 37 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 74.36% |
25.2%
49.2 pts better
|
Numerator 29 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.6
0.4 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.4 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.2
0.2 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.9 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.5% |
95.7%
8.2 pts worse
|
93.4%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.8% · Q2 89.3% · Q3 88.0% · Q4 85.2% · 4Q avg 87.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.5% |
95.0%
0.5 pts worse
|
95.5%
1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.2%
0.5 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.4% · Q3 2.4% · Q4 2.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
5.0%
3.7 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 1.3% · Q4 1.2% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
4.9%
0.9 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 9.2% · Q3 6.2% · Q4 1.5% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.5% |
16.6%
1.1 pts better
|
19.6%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 16.9% · Q3 14.1% · Q4 13.8% · 4Q avg 15.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
16.7%
9.9 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.6% · Q3 6.9% · Q4 9.1% · 4Q avg 6.8% · 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 | 16.5% |
21.1%
4.6 pts better
|
16.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 15.6% · Q3 19.9% · Q4 6.4% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.6% |
17.3%
5.7 pts better
|
14.9%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 14.8% · Q3 9.8% · Q4 9.4% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.1% |
2.3%
0.8 pts worse
|
1.0%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.3% · Q3 2.0% · Q4 1.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
3.0%
0.3 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.8% · Q3 1.2% · Q4 4.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.2% |
25.5%
6.7 pts worse
|
19.8%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 27.9% · Q3 38.2% · Q4 33.1% · 4Q avg 32.2% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
5.5%
0.7 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 6.0% · Q3 5.6% · Q4 2.8% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.3% |
86.8%
4.5 pts worse
|
81.7%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 87.3% · Q3 74.6% · Q4 75.8% · 4Q avg 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
15.0%
1.2 pts better
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 12.5% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.3%
1.1 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.4% · Q3 2.6% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.6% |
82.2%
2.6 pts worse
|
79.7%
0.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.1% |
22.7%
0.6 pts better
|
23.9%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 18.8% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-13 · Fire 2024-02-13
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-10-24 · Fire 2022-10-24
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-03
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-06-03
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 2025-06-27
D · Potential for more than minimal harm
2025-06-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-06-03
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-07-04
D · Potential for more than minimal harm
2025-06-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-08-12
C · Minimal harm
2025-06-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-18
D · Potential for more than minimal harm
2024-02-13
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-27
E · Potential for more than minimal harm
2022-10-24
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-07-25
E · Potential for more than minimal harm
2022-10-24
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-10-24
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 2022-11-24
D · Potential for more than minimal harm
2022-10-24
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-11-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-03
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 2025-06-30
D · Potential for more than minimal harm
2025-06-03
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-06-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-01
E · Potential for more than minimal harm
2024-02-13
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 2024-03-08
D · Potential for more than minimal harm
2024-02-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-13
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 2024-03-13
D · Potential for more than minimal harm
2024-02-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-13
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 2024-03-06
D · Potential for more than minimal harm
2024-02-13
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 2024-03-08
D · Potential for more than minimal harm
2024-02-13
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-03-08
F · Potential for more than minimal harm
2022-10-24
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 2022-11-24
D · Potential for more than minimal harm
2022-10-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-24
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-24
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 2022-11-24
Penalties and ownership
What sits behind the stars
Ownership
Mch Services Inc
5% Or Greater Direct Ownership Interest · Organization
Brauer, Michael
Corporate Director · Individual
Brooks, Mary
Corporate Director · Individual
Carlson, Michele
Operational/Managerial Control · Individual
Coffey, Bridget
Corporate Director · Individual
Connelly, Paul
Corporate Director · Individual
De Vita, Robert
Corporate Director · Individual
Doering, Jennifer
Corporate Director · Individual
Doering, Jennifer
Corporate Officer · Individual
Fulcher, David
Operational/Managerial Control · Individual
Fulcher, David
Corporate Officer · Individual
Gerou, Kate
Operational/Managerial Control · Individual
Grant, Kathleen
Operational/Managerial Control · Individual
Hill, Joanne
Corporate Director · Individual
Horning, Jessica
Operational/Managerial Control · Individual
Horning, Jessica
Corporate Officer · Individual
Leadingchoice Network LLC
Operational/Managerial Control · Organization
Mullaney, Peter
Corporate Officer · Individual
Olenchek, Lora
Corporate Director · Individual
Olenchek, Lora
Corporate Officer · Individual
Pickart, Joseph
Corporate Director · Individual
Price-Topp, Linda
Corporate Director · Individual
Schmidt, Richard
Corporate Director · Individual
Schmidt, Richard
Corporate Officer · Individual
Volberding, James
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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5-star overall rating with 5-star inspections with $99,452 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Edenbrook Lakeside
Milwaukee, WI
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
#3
Saint Johns On The Lake
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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