4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Milwaukee, WI
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
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
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
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
| 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
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-02-07
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-02-07
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-02-07
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-04
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-07
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-18
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-07
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-10
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-07
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2025-02-07
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
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-12-05
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-11-10
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-10
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-10
Inspection history
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-08-26
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
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-02-26
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-26
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-09
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
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-13
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-12-13
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-12-13
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
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-13
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-13
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
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
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