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
Staffing
Hours and turnover
RN hours / resident day
1.12
Registered nurse staffing
LPN hours / resident day
0.76
Licensed practical nurse staffing
Aide hours / resident day
4.06
Nurse aide staffing
Weekend hours
5.49
Weekend nurse staffing
RN turnover
20%
Annual RN turnover
Total nurse turnover
39%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 16.5% |
21.1%
4.6 pts better
|
16.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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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
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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
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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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