Wauwatosa, WI
3-star overall rating with 2-star inspections with $90,430 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
10101 W Wisconsin Ave, Wauwatosa, WI
(414) 258-1814
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
50
Certified beds
Average residents
42
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
1.20
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.31
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.94
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.36
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.10
CMS adjusted RN staffing hours
Adjusted total hours
3.98
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
954
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.73
Composite VBP score used to determine payment impact.
Payment multiplier
1.0167
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
8.66
Baseline 20.41% · Performance 17.42% · Measure score 8.66 · Achievement 8.66 · Improvement 8.34
Healthcare-associated infections
6.50
Baseline 5.88% · Performance 5.89% · Measure score 6.50 · Achievement 6.50 · Improvement 0
Total nurse turnover
5.71
Baseline 38.46% · Performance 40.32% · Measure score 5.71 · Achievement 5.71 · Improvement 0
Adjusted total nurse staffing
3.82
Baseline 4.68 hours · Performance 4.16 hours · Measure score 3.82 · Achievement 3.82 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.19% |
10.72%
2.5 pts better
|
No Different than the National Rate · Eligible stays 150 · Observed rate 3.33% · Lower 95% interval 5.12% |
| Discharge to community | 68.07% |
50.57%
17.5 pts better
|
Better than the National Rate · Eligible stays 120 · Observed rate 65.83% · Lower 95% interval 59.71% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 76 · Denominator 76 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 76 |
| Discharge self-care score | 51.56% |
53.69%
2.1 pts worse
|
Numerator 33 · Denominator 64 |
| Discharge mobility score | 34.38% |
50.94%
16.6 pts worse
|
Numerator 22 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 3.95% |
2.29%
1.7 pts worse
|
Numerator 3 · Denominator 76 · Adjusted rate 4.97% |
| Healthcare-associated infections requiring hospitalization | 5.89% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 1.49% · Lower 95% interval 2.8% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 218 |
| Staff flu vaccination coverage | 93.88% |
42%
51.9 pts better
|
Numerator 138 · Denominator 147 |
| Discharge function score | 53.13% |
56.45%
3.3 pts worse
|
Numerator 34 · Denominator 64 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 43.24% |
25.2%
18 pts better
|
Numerator 16 · Denominator 37 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
95.7%
3.3 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
5.0%
4 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.9%
4.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.9% |
16.6%
10.7 pts better
|
19.6%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
16.7%
16.7 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 need for help with daily activities has increased | 17.4% |
17.3%
0.1 pts worse
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
2.3%
1.4 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 2.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
3.0%
2 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.8% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.6% |
25.5%
9.1 pts worse
|
19.8%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 44.4% · 4Q avg 34.6% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
5.5%
1.1 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 6.5% · Q3 6.0% · Q4 2.8% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
86.8%
8.3 pts better
|
81.7%
13.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 96.8% · Q3 95.2% · Q4 91.9% · 4Q avg 95.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.2% |
15.0%
8.8 pts better
|
12.0%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.2% · Observed 5.3% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.3%
About the same
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.6% · Q3 1.3% · Q4 1.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
82.2%
13.5 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.0% |
22.7%
8.3 pts worse
|
23.9%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.0% · Observed 22.7% · Expected 17.4% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Pharmacy Service (4 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-05-13
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-13
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-14
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-13
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-13
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-14
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-15
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-01-25
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 2024-01-25
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-02-19
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-11-01
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 2022-10-19
Inspection history
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-09-04
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-13
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-13
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 2025-05-13
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-13
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 2025-05-13
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-02
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-21
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-21
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-02
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-02
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-21
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-02-21
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 2024-02-21
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-21
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-10-24
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-24
Penalties and ownership
Fine · fine $70,140
Fine
Fine · fine $20,290
Fine
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Nearby options
West Allis, WI
1-star overall rating with 1-star inspections with $341,867 in total fines with 23 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Wauwatosa, WI
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Milwaukee, WI
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
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