Milwaukee, WI

St Anne's Salvatorian Campus

2-star overall rating with 1-star inspections with $326,060 in total fines with 26 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

3800 N 92nd St, Milwaukee, WI

(414) 463-7570

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

50

Certified beds

Average residents

30

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1994-02-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

1.27

Registered nurse staffing

LPN hours / resident day

0.46

Licensed practical nurse staffing

Aide hours / resident day

2.68

Nurse aide staffing

Weekend hours

4.08

Weekend nurse staffing

RN turnover

33%

Annual RN turnover

Total nurse turnover

58%

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 85.2%
95.7%
10.5 pts worse
93.4%
8.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 91.9%
95.0%
3.1 pts worse
95.5%
3.6 pts worse
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 6.6%
3.2%
3.4 pts worse
3.3%
3.3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 0.0%
5.0%
5 pts better
11.4%
11.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 2.1%
4.9%
2.8 pts better
5.4%
3.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 14.3%
16.6%
2.3 pts better
19.6%
5.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 7.6%
16.7%
9.1 pts better
16.7%
9.1 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 need for help with daily activities has increased 12.6%
17.3%
4.7 pts better
14.9%
2.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 3.3%
2.3%
1 pts worse
1.0%
2.3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 5.0%
3.0%
2 pts worse
1.7%
3.3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 29.1%
25.5%
3.6 pts worse
19.8%
9.3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 6.9%
5.5%
1.4 pts worse
5.1%
1.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 57.1%
86.8%
29.7 pts worse
81.7%
24.6 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 21.6%
15.0%
6.6 pts worse
12.0%
9.6 pts worse
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 2.5%
1.3%
1.2 pts worse
1.6%
0.9 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 59.1%
82.2%
23.1 pts worse
79.7%
20.6 pts worse
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 23.4%
22.7%
0.7 pts worse
23.9%
0.5 pts better
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-14 · Fire 2024-11-14

26 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

6 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Cycle 2 Health 2023-08-17 · Fire 2023-08-17

32 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2022-06-08 · Fire 2022-06-08

3 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

6 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-11-14

E18 · Emergency Preparedness Deficiencies

Fire Safety

Establish procedures for tracking staff and patients during an emergency.

Corrected 2024-12-19

F · Potential for more than minimal harm 2024-11-14

E35 · Emergency Preparedness Deficiencies

Fire Safety

Provide family notifications of emergency plan.

Corrected 2024-12-19

F · Potential for more than minimal harm 2024-11-14

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-12-19

E · Potential for more than minimal harm 2024-11-14

K132 · Construction Deficiencies

Fire Safety

Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

Corrected 2024-12-19

D · Potential for more than minimal harm 2024-11-14

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2024-12-19

C · Minimal harm 2024-11-14

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-12-19

E · Potential for more than minimal harm 2023-08-17

K132 · Construction Deficiencies

Fire Safety

Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

Corrected 2023-08-25

E · Potential for more than minimal harm 2023-08-17

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 2023-08-25

E · Potential for more than minimal harm 2023-08-17

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-08-25

D · Potential for more than minimal harm 2023-08-17

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-08-21

D · Potential for more than minimal harm 2023-08-17

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-08-21

C · Minimal harm 2023-08-17

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-08-22

F · Potential for more than minimal harm 2022-06-08

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2022-07-05

E · Potential for more than minimal harm 2022-06-08

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 2022-07-05

E · Potential for more than minimal harm 2022-06-08

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-08-06

E · Potential for more than minimal harm 2022-06-08

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-07-01

E · Potential for more than minimal harm 2022-06-08

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2022-07-05

E · Potential for more than minimal harm 2022-06-08

K374 · Smoke Deficiencies

Fire Safety

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

Corrected 2022-07-05

Inspection history

Recent health citations

G · Actual harm 2026-01-07

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 2026-02-02

D · Potential for more than minimal harm 2026-01-07

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2026-02-02

D · Potential for more than minimal harm 2025-06-13

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-07-11

D · Potential for more than minimal harm 2025-06-13

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-07-11

D · Potential for more than minimal harm 2025-06-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-11

G · Actual harm 2025-03-05

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-04-15

G · Actual harm 2024-11-14

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-04-15

G · Actual harm 2024-11-14

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 2025-04-15

F · Potential for more than minimal harm 2024-11-14

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2024-12-19

F · Potential for more than minimal harm 2024-11-14

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-15

E · Potential for more than minimal harm 2024-11-14

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 2024-12-19

E · Potential for more than minimal harm 2024-11-14

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-12-19

D · Potential for more than minimal harm 2024-11-14

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-12-19

D · Potential for more than minimal harm 2024-11-14

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-12-19

D · Potential for more than minimal harm 2024-11-14

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-12-19

D · Potential for more than minimal harm 2024-11-14

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-12-19

D · Potential for more than minimal harm 2024-11-14

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-12-19

D · Potential for more than minimal harm 2024-11-14

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-04-15

D · Potential for more than minimal harm 2024-11-14

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-12-19

D · Potential for more than minimal harm 2024-11-14

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-12-19

D · Potential for more than minimal harm 2024-11-14

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 2024-12-19

D · Potential for more than minimal harm 2024-11-14

F745 · Quality of Life and Care Deficiencies

Health

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected 2024-12-19

D · Potential for more than minimal harm 2024-11-14

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-12-19

D · Potential for more than minimal harm 2024-11-14

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 2024-12-19

D · Potential for more than minimal harm 2024-11-14

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2024-12-19

D · Potential for more than minimal harm 2024-11-14

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-12-19

D · Potential for more than minimal harm 2024-08-07

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-08-24

D · Potential for more than minimal harm 2024-08-07

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-08-24

J · Immediate jeopardy 2023-08-17

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-09-13

J · Immediate jeopardy 2023-08-17

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-09-13

J · Immediate jeopardy 2023-08-17

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-09-13

F · Potential for more than minimal harm 2023-08-17

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 2023-09-13

F · Potential for more than minimal harm 2023-08-17

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2023-09-13

F · Potential for more than minimal harm 2023-08-17

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2023-09-13

F · Potential for more than minimal harm 2023-08-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-09-13

F · Potential for more than minimal harm 2023-08-17

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2023-09-13

E · Potential for more than minimal harm 2023-08-17

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2023-09-13

E · Potential for more than minimal harm 2023-08-17

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-09-13

E · Potential for more than minimal harm 2023-08-17

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-09-13

E · Potential for more than minimal harm 2023-08-17

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-09-13

E · Potential for more than minimal harm 2023-08-17

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 2023-09-13

E · Potential for more than minimal harm 2023-08-17

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 2023-09-13

E · Potential for more than minimal harm 2023-08-17

F941 · Administration Deficiencies

Health

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Corrected 2023-09-13

E · Potential for more than minimal harm 2023-08-17

F949 · Administration Deficiencies

Health

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Corrected 2023-09-13

D · Potential for more than minimal harm 2023-08-17

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 2023-09-13

D · Potential for more than minimal harm 2023-08-17

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-09-13

D · Potential for more than minimal harm 2023-08-17

F687 · Quality of Life and Care Deficiencies

Health

Provide appropriate foot care.

Corrected 2023-09-13

D · Potential for more than minimal harm 2023-08-17

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2023-09-13

D · Potential for more than minimal harm 2023-08-17

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 2023-09-13

D · Potential for more than minimal harm 2023-08-17

F745 · Quality of Life and Care Deficiencies

Health

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected 2023-09-13

D · Potential for more than minimal harm 2023-08-17

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 2023-09-13

D · Potential for more than minimal harm 2023-08-17

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2023-09-13

D · Potential for more than minimal harm 2023-08-17

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 2023-09-13

D · Potential for more than minimal harm 2023-08-17

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-09-13

D · Potential for more than minimal harm 2023-08-17

F773 · Administration Deficiencies

Health

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Corrected 2023-09-13

D · Potential for more than minimal harm 2023-08-17

F909 · Environmental Deficiencies

Health

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Corrected 2023-09-13

B · Minimal harm 2023-08-17

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 2023-09-13

B · Minimal harm 2023-08-17

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2023-09-13

D · Potential for more than minimal harm 2022-06-08

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2022-07-05

D · Potential for more than minimal harm 2022-06-08

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-07-05

D · Potential for more than minimal harm 2022-06-08

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2022-07-05

Penalties and ownership

What sits behind the stars

$204,523 2024-11-14

Fine

Fine · fine $204,523

Fine

$0 2024-11-14

Payment Denial

Payment Denial · denial start 2024-12-24 · 112 days

112 day denial

$121,537 2023-08-17

Fine

Fine · fine $121,537

Fine

Ownership

Marquardt Village Inc

5% Or Greater Direct Ownership Interest · Organization

100% 5 facilities 2022-01-04
Dettman, Scott

Corporate Director · Individual

0% 7 facilities 2022-01-04
Fischer, Todd

Corporate Director · Individual

0% 7 facilities 2022-01-04
Heroux, Steven

Corporate Director · Individual

0% 6 facilities 2024-08-01
Illuminus Inc

Operational/Managerial Control · Organization

0% 10 facilities 2022-01-04
Kohlhoff, Kevin

Corporate Director · Individual

0% 6 facilities 2023-09-01
Konkol, Dennis

Corporate Director · Individual

0% 6 facilities 2024-10-01
Lipke, Tesla

Operational/Managerial Control · Individual

0% 1 facilities 2025-04-16
Marks, Julie

Operational/Managerial Control · Individual

0% 9 facilities 2025-06-09
Marks, Julie

Corporate Officer · Individual

0% 9 facilities 2025-06-09
Marquardt Village Inc

Operational/Managerial Control · Organization

0% 5 facilities 2022-01-04
Mauthe, Matthew

Operational/Managerial Control · Individual

0% 11 facilities 2022-01-04
Mauthe, Matthew

Corporate Officer · Individual

0% 11 facilities 2022-01-04
Meidenbauer, Robert

Corporate Director · Individual

0% 7 facilities 2022-01-04
Sidhu, Sarfraz

Operational/Managerial Control · Individual

0% 15 facilities 2021-07-02
Van Der Linden, Katie

Corporate Director · Individual

0% 5 facilities 2022-01-04
Wagner, Lynne

Corporate Director · Individual

0% 6 facilities 2024-10-01

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