Milwaukee, WI

Milwaukee Health and Rehab

4-star overall rating with 4-star inspections with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle

3216 W Highland Blvd, Milwaukee, WI

(414) 344-6515

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Avina Healthcare

Operator or chain grouping

Approved since

1989-02-09

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

8 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

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

0.42

Registered nurse staffing · state 0.97 · national 0.68

LPN hours / resident day

1.08

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

1.40

Nurse aide staffing · state 2.59 · national 2.35

Total nurse hours

2.90

All reported nurse hours · state 4.20 · national 3.89

Licensed hours

1.50

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

2.40

Weekend nurse staffing · state 3.72 · national 3.43

Weekend RN hours

0.23

Weekend registered nurse coverage · state 0.66 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.43

CMS adjusted RN staffing hours

Adjusted total hours

2.97

CMS adjusted total nurse staffing hours

Case-mix index

1.34

Higher values indicate more complex resident acuity

RN turnover

17%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

50%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,446

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

12.20

Composite VBP score used to determine payment impact.

Payment multiplier

0.9811

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

2.44

Baseline 56.76% · Performance 53.70% · Measure score 2.44 · Achievement 2.44 · Improvement 0.46

Adjusted total nurse staffing

Baseline 3.13 hours · Performance 2.99 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.03%	10.72% 0.3 pts worse	No Different than the National Rate · Eligible stays 26 · Observed rate 19.23% · Lower 95% interval 6.98%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	0.98	1.02 About the same
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 17 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	6.67%	8.2% 1.5 pts worse	Numerator 6 · Denominator 90
Staff flu vaccination coverage	21.11%	42% 20.9 pts worse	Numerator 19 · Denominator 90
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	76.7%	95.7% 19 pts worse	93.4% 16.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 77.0% · Q2 74.1% · Q3 74.6% · Q4 81.5% · 4Q avg 76.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	75.0%	95.0% 20 pts worse	95.5% 20.5 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 75.0%
Percentage of long-stay residents experiencing one or more falls with major injury	3.0%	3.2% 0.2 pts better	3.3% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.4% · Q3 3.4% · Q4 1.9% · 4Q avg 3.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	9.3%	5.0% 4.3 pts worse	11.4% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 13.0% · Q3 5.7% · Q4 1.9% · 4Q avg 9.3%
Percentage of long-stay residents who lose too much weight	8.7%	4.9% 3.8 pts worse	5.4% 3.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 21.2% · Q3 1.9% · Q4 8.2% · 4Q avg 8.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	13.3%	16.6% 3.3 pts better	19.6% 6.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 11.3% · Q3 14.8% · Q4 14.0% · 4Q avg 13.3%
Percentage of long-stay residents who received an antipsychotic medication	28.8%	16.7% 12.1 pts worse	16.7% 12.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 35.5% · Q2 36.7% · Q3 28.1% · Q4 15.6% · 4Q avg 28.8% · 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	6.9%	21.1% 14.2 pts better	16.3% 9.4 pts better	Long Stay · 2024Q4-2025Q3 · Q3 5.8% · 4Q avg 6.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	9.3%	17.3% 8 pts better	14.9% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 9.6% · Q3 11.3% · Q4 8.3% · 4Q avg 9.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	2.3% 1.4 pts better	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.4%	3.0% 2.6 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.5%	25.5% 5 pts better	19.8% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 19.7% · Q3 30.6% · Q4 17.6% · 4Q avg 20.5%
Percentage of long-stay residents with pressure ulcers	8.7%	5.5% 3.2 pts worse	5.1% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 14.7% · Q3 5.4% · Q4 2.1% · 4Q avg 8.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	65.3%	86.8% 21.5 pts worse	81.7% 16.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 57.1% · Q2 54.5% · Q3 71.7% · Q4 76.2% · 4Q avg 65.3%
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 · Q2 5.0% · Q3 4.0% · 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	31.1%	82.2% 51.1 pts worse	79.7% 48.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 31.1%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-08 · Fire 2025-12-08

5 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

11 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-07-24 · Fire 2024-07-24

7 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

15 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2023-04-13 · Fire 2023-04-13

9 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

14 fire-safety deficiencies

Top issue: Smoke (7 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-12-08

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-12-30

F · Potential for more than minimal harm 2025-12-08

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2026-01-08

E · Potential for more than minimal harm 2025-12-08

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 2025-12-31

E · Potential for more than minimal harm 2025-12-08

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2025-12-30

D · Potential for more than minimal harm 2025-12-08

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2026-01-08

D · Potential for more than minimal harm 2025-12-08

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 2026-01-08

D · Potential for more than minimal harm 2025-12-08

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2025-12-30

D · Potential for more than minimal harm 2025-12-08

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-12-31

D · Potential for more than minimal harm 2025-12-08

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2026-01-08

C · Minimal harm 2025-12-08

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-12-30

C · Minimal harm 2025-12-08

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-12-31

F · Potential for more than minimal harm 2024-07-24

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2024-08-22

F · Potential for more than minimal harm 2024-07-24

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-08-22

F · Potential for more than minimal harm 2024-07-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-08-22

F · Potential for more than minimal harm 2024-07-24

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-08-22

F · Potential for more than minimal harm 2024-07-24

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-08-22

F · Potential for more than minimal harm 2024-07-24

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2024-08-22

F · Potential for more than minimal harm 2024-07-24

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-08-22

E · Potential for more than minimal harm 2024-07-24

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-08-22

E · Potential for more than minimal harm 2024-07-24

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2024-09-19

E · Potential for more than minimal harm 2024-07-24

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-08-22

E · Potential for more than minimal harm 2024-07-24

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-08-22

E · Potential for more than minimal harm 2024-07-24

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-08-22

E · Potential for more than minimal harm 2024-07-24

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-08-22

E · Potential for more than minimal harm 2024-07-24

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-08-22

D · Potential for more than minimal harm 2024-07-24

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 2024-08-22