Milwaukee, WI

St Ann Health And Rehabilitation Center

3-star overall rating with 4-star inspections with 4 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle

2020 S Muskego Ave, Milwaukee, WI

(414) 383-2630

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

50

Certified beds

Average residents

46

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Champion Care

Operator or chain grouping

Approved since

2023-12-08

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.68

Registered nurse staffing

LPN hours / resident day

0.73

Licensed practical nurse staffing

Aide hours / resident day

2.62

Nurse aide staffing

Weekend hours

3.72

Weekend nurse staffing

RN turnover

0%

Annual RN turnover

Total nurse turnover

0%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 92.0%
95.7%
3.7 pts worse
93.4%
1.4 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 91.3%
95.0%
3.7 pts worse
95.5%
4.2 pts worse
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 3.1%
3.2%
0.1 pts better
3.3%
0.2 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 5.1%
5.0%
0.1 pts worse
11.4%
6.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 11.2%
4.9%
6.3 pts worse
5.4%
5.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 24.6%
16.6%
8 pts worse
19.6%
5 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 19.6%
16.7%
2.9 pts worse
16.7%
2.9 pts worse
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 22.7%
21.1%
1.6 pts worse
16.3%
6.4 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 16.3%
17.3%
1 pts better
14.9%
1.4 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 1.3%
2.3%
1 pts better
1.0%
0.3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 3.8%
3.0%
0.8 pts worse
1.7%
2.1 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 20.4%
25.5%
5.1 pts better
19.8%
0.6 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 4.3%
5.5%
1.2 pts better
5.1%
0.8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 55.6%
86.8%
31.2 pts worse
81.7%
26.1 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 25.6%
15.0%
10.6 pts worse
12.0%
13.6 pts worse
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 2.0%
1.3%
0.7 pts worse
1.6%
0.4 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 60.5%
82.2%
21.7 pts worse
79.7%
19.2 pts worse
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 27.7%
22.7%
5 pts worse
23.9%
3.8 pts worse
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-06 · Fire 2025-02-06

4 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

10 fire-safety deficiencies

Top issue: Emergency Preparedness (4 deficiencies)

Cycle 2 Health 2023-11-13 · Fire 2023-11-13

10 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-06

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2025-02-07

F · Potential for more than minimal harm 2025-02-06

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2025-02-07

F · Potential for more than minimal harm 2025-02-06

E35 · Emergency Preparedness Deficiencies

Fire Safety

Provide family notifications of emergency plan.

Corrected 2025-02-07

F · Potential for more than minimal harm 2025-02-06

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-03-04

F · Potential for more than minimal harm 2025-02-06

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-02-07

E · Potential for more than minimal harm 2025-02-06

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-02-18

E · Potential for more than minimal harm 2025-02-06

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-02-07

D · Potential for more than minimal harm 2025-02-06

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-02-10

D · Potential for more than minimal harm 2025-02-06

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-02-07

D · Potential for more than minimal harm 2025-02-06

K925 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that sources of ignition are removed from patients receiving respiratory therapy.

Corrected 2025-02-07

E · Potential for more than minimal harm 2023-11-13

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 2023-11-10

E · Potential for more than minimal harm 2023-11-13

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2023-12-05

E · Potential for more than minimal harm 2023-11-13

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2023-11-10

E · Potential for more than minimal harm 2023-11-13

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-11-10

D · Potential for more than minimal harm 2023-11-13

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-11-10

D · Potential for more than minimal harm 2023-11-13

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-11-10

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-01

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2025-08-26

F · Potential for more than minimal harm 2025-02-06

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 2025-02-26

D · Potential for more than minimal harm 2025-02-06

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-02-26

D · Potential for more than minimal harm 2025-02-06

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-02-26

E · Potential for more than minimal harm 2024-10-17

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-11-15

D · Potential for more than minimal harm 2024-03-14

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 2024-04-09

E · Potential for more than minimal harm 2023-11-13

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 2023-12-13

E · Potential for more than minimal harm 2023-11-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-12-13

D · Potential for more than minimal harm 2023-11-13

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2023-12-13

D · Potential for more than minimal harm 2023-11-13

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2023-12-13

D · Potential for more than minimal harm 2023-11-13

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2023-12-13

D · Potential for more than minimal harm 2023-11-13

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-12-13

D · Potential for more than minimal harm 2023-11-13

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-12-13

C · Minimal harm 2023-11-13

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2023-12-13

Penalties and ownership

What sits behind the stars

Ownership

The Bay At St Ann Holdings LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2020-09-21
Ruvel, Menachem

5% Or Greater Indirect Ownership Interest · Individual

48% 21 facilities 2020-09-21
Weinberg, Yisroel

5% Or Greater Indirect Ownership Interest · Individual

48% 21 facilities 2020-09-21
Champion Care LLC

Operational/Managerial Control · Organization

0% 12 facilities 2020-12-01
Ruvel, Menachem

Operational/Managerial Control · Individual

0% 21 facilities 2020-12-01
Ruvel, Menachem

Corporate Director · Individual

0% 21 facilities 2020-09-21
Weinberg, Yisroel

Operational/Managerial Control · Individual

0% 21 facilities 2020-12-01
Weinberg, Yisroel

Corporate Director · Individual

0% 21 facilities 2020-09-21

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Staffing
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1-star overall rating with 1-star inspections with $175,897 in total fines with 39 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

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Staffing
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#3

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3-star overall rating with 3-star inspections with $15,872 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

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Staffing
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Fines
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