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)
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
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
Chain footprint
21 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
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
0.68
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.03
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.72
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.40
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
0.64
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.17% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 14.29% · Lower 95% interval 7.52% |
| Discharge to community | 38.57% |
50.57%
12 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 25% · Lower 95% interval 26.82% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.67% |
95.27%
1.4 pts better
|
Numerator 29 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 1 · Denominator 30 · Adjusted rate 3.3% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · 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 | 92.0% |
95.7%
3.7 pts worse
|
93.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 88.6% · Q3 89.5% · Q4 90.0% · 4Q avg 92.0% |
| 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 · 4Q avg 91.3% |
| 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 · Q1 2.5% · Q2 2.3% · Q3 2.6% · Q4 5.0% · 4Q avg 3.1% · Used in QM five-star |
| 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 · Q1 3.2% · Q2 5.7% · Q3 3.0% · Q4 8.1% · 4Q avg 5.1% |
| 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 · Q1 6.1% · Q2 15.8% · Q3 6.1% · Q4 16.7% · 4Q avg 11.2% |
| 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 · Q1 17.6% · Q2 23.7% · Q3 35.3% · Q4 21.9% · 4Q avg 24.6% |
| 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 · Q1 27.3% · Q2 20.0% · Q3 11.5% · Q4 20.8% · 4Q avg 19.6% · 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 | 22.7% |
21.1%
1.6 pts worse
|
16.3%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.7% · Used in QM five-star |
| 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 · Q1 20.0% · Q2 14.7% · Q3 6.9% · Q4 23.3% · 4Q avg 16.3% · Used in QM five-star |
| 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 · Q1 5.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 4.5% · Q3 5.4% · Q4 5.3% · 4Q avg 3.8% · Used in QM five-star |
| 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 · Q1 12.4% · Q2 22.1% · Q3 22.1% · Q4 23.9% · 4Q avg 20.4% |
| 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 · Q1 6.7% · Q2 3.7% · Q3 3.9% · Q4 3.1% · 4Q avg 4.3% · Used in QM five-star |
| 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 · Q1 43.5% · Q2 61.9% · Q3 64.6% · Q4 52.9% · 4Q avg 55.6% |
| 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 · Adjusted 25.6% · Observed 25.0% · Expected 10.9% · Used in QM five-star |
| 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 · Q1 9.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| 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 · 4Q avg 60.5% |
| 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 · Adjusted 27.7% · Observed 25.0% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
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
Ruvel, Menachem
5% Or Greater Indirect Ownership Interest · Individual
Weinberg, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Champion Care LLC
Operational/Managerial Control · Organization
Ruvel, Menachem
Operational/Managerial Control · Individual
Ruvel, Menachem
Corporate Director · Individual
Weinberg, Yisroel
Operational/Managerial Control · Individual
Weinberg, Yisroel
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Mercy Health Services
Milwaukee, WI
3-star overall rating with 3-star inspections with $47,753 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Wheaton Franciscan Hc - Terrace At St Francis
Milwaukee, WI
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
#3
Aria At Mitchell Manor
West Allis, WI
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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