Federal inspection record · CMS data as of October 1, 2026
St. Anne's Salvatorian Campus
3800 N 92nd St, Milwaukee, WI · (414) 463-7570
- Certified beds
- 50
- Residents per day
- 37
- Ownership
- For-Profit
- Chain
- Illuminus
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- February 1, 1994
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Wisconsin.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Wisconsin homes
St. Anne's Salvatorian Campus carries 195.25 inspection points. That is fewer than 12% of Wisconsin's 321 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Wisconsin: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–11 pts
- 4★ 11–37 pts
- 3★ 37–76 pts
- 2★ 76–130.75 pts
- 1★ over 130.75 pts
Bars show every rated home in Wisconsin by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
67 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (8)
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Ensure that residents are free from significant medication errors.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
J
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
-
J
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Everything else, by area of care
Quality of Life and Care12E
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
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.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate foot care.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
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.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Resident Rights11F
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
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.
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
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.
- D
Keep residents' personal and medical records private and confidential.
- F
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.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- B
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- B
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.
Pharmacy Service9E
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure medication error rates are not 5 percent or greater.
- D
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.
- E
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.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
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.
- D
Ensure medication error rates are not 5 percent or greater.
Infection Control8F
- F
Provide and implement an infection prevention and control program.
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
- D
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
- D
Implement a program that monitors antibiotic use.
- F
Provide and implement an infection prevention and control program.
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Freedom from Abuse, Neglect, and Exploitation5D
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
- D
Respond appropriately to all alleged violations.
Resident Assessment and Care Planning5E
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Administration5F
- F
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.
- D
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.
- E
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
- E
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Nursing and Physician Services3F
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- F
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.
Environmental1D
- D
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.
Inspection history
2026-03-26
11 health deficiencies · 3 fire-safety deficiencies
Top issue: Infection Control (3 deficiencies)
2024-11-14
24 health deficiencies · 6 fire-safety deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2023-08-17
32 health deficiencies · 6 fire-safety deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 39 min of nursing staff time a day, 1 h 2 min of it from a registered nurse.
This home
3 h 39 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 37% of nursing staff and 18% of registered nurses left in the past year, along with 2 administrators.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$343,488 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2026-03-26 | Fine | $119,850 |
| 2026-03-26 | Payment Denial · 21 day denial | $0 |
| 2026-01-07 | Fine | $19,115 |
| 2026-01-07 | Payment Denial · 23 day denial | $0 |
| 2024-11-14 | Fine | $204,523 |
| 2024-11-14 | Payment Denial · 112 day denial | $0 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.4 pts better | 96.4% | 96.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine1.2 pts better | 96.8% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.2 pts worse | 5.5% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms6 pts better | 0.0% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.6 pts better | 3.3% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.5 pts better | 16.3% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication2.7 pts better | 13.2% | 15.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened5.4 pts better | 11.6% | 17.0% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased3 pts better | 12.8% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder2.3 pts worse | 4.2% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.1 pts worse | 2.8% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence9.8 pts worse | 33.4% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.4 pts better | 4.5% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine37.8 pts worse | 49.1% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit1.6 pts better | 14.0% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication2.1 pts worse | 3.3% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine22.2 pts worse | 60.0% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission11.5 pts worse | 34.0% | 22.5% | 23.4% |
·
Who owns and runs it
22 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Marquardt Village Inc | 5% Or Greater Direct Ownership Interest · Organization | 100% | 6 facilities |
| Dettman, Scott | Corporate Director · Individual | 0% | 8 facilities |
| Fischer, Todd | Corporate Director · Individual | 0% | 8 facilities |
| Heroux, Steven | Corporate Director · Individual | 0% | 7 facilities |
| Illuminus Inc | Operational/Managerial Control · Organization | 0% | 11 facilities |
| Illuminus Inc | Adp Of The SNF · Organization | 0% | 11 facilities |
| Kohlhoff, Kevin | Corporate Director · Individual | 0% | 7 facilities |
| Konkol, Dennis | Corporate Director · Individual | 0% | 7 facilities |
| Lipke, Tesla | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Lipke, Tesla | Adp Of The SNF · Individual | 0% | 1 facilities |
| Marks, Julie | Corporate Officer · Individual | 0% | 11 facilities |
| Marks, Julie | Operational/Managerial Control · Individual | 0% | 11 facilities |
| Marks, Julie | Adp Of The SNF · Individual | 0% | 11 facilities |
| Marquardt Village Inc | Operational/Managerial Control · Organization | 0% | 6 facilities |
| Mauthe, Matthew | Corporate Officer · Individual | 0% | 11 facilities |
| Mauthe, Matthew | Operational/Managerial Control · Individual | 0% | 11 facilities |
| Mauthe, Matthew | Adp Of The SNF · Individual | 0% | 11 facilities |
| Meidenbauer, Robert | Corporate Director · Individual | 0% | 8 facilities |
| Sidhu, Sarfraz | Operational/Managerial Control · Individual | 0% | 28 facilities |
| Sidhu, Sarfraz | Adp Of The SNF · Individual | 0% | 28 facilities |
| Van Der Linden, Katie | Corporate Director · Individual | 0% | 6 facilities |
| Wagner, Lynne | Corporate Director · Individual | 0% | 7 facilities |
·
Fire safety
15 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Egress3E
- E
Have properly located and lighted "Exit" signs.
- C
Install emergency lighting that can last at least 1 1/2 hours.
- E
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.
Smoke3E
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Install corridor and hallway doors that block smoke.
- D
Provide properly protected cooking facilities.
Emergency Preparedness3F
- F
Establish procedures for tracking staff and patients during an emergency.
- F
Provide family notifications of emergency plan.
- F
Conduct testing and exercise requirements.
Gas, Vacuum, and Electrical Systems2D
- D
Have proper medical gas storage and administration areas.
- C
Have generator or other power source capable of supplying service within 10 seconds.
Construction2E
- E
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
- E
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Miscellaneous1D
- D
Have restrictions on the use of portable space heaters.
Services1D
- D
Have properly installed electrical wiring and gas equipment.
·
Other homes nearby
-
Luther Manor
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★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 4 h 52 min
- Fines
- $163,627
-
Lutheran Home
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- Nursing / resident / day
- 4 h 26 min
- Fines
- $0
-
Congregational Home, Inc.
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★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 6 h 26 min
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