Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Milwaukee Health And Rehab during CMS and state inspections, most recent first.
A resident with right-sided hemiplegia and a right-hand contracture did not have the ordered right-hand splint in place, despite the care plan calling for a splint for contraction prevention. Surveyors observed the resident without the splint on two occasions, and a CNA was unsure of the need for it, could not find it, and was told by an LPN to use a towel instead.
Failure to provide proper incontinence care: A resident with dementia, Alzheimer’s disease, and urinary retention was dependent on staff for toileting and was always incontinent of bowel and bladder. The care plan directed briefs to be changed every 2 to 3 hours with incontinence checks and peri care, but the resident was observed double briefed, with a strong urine odor and briefs soaked through to the chuck pad. An LPN stated no one should be double briefed, and the NHA said double briefing is not allowed and is not endorsed by the facility.
Inaccurate PBJ Staffing Submission: Survey review found the facility’s PBJ staffing data for Q2 showed excessively low weekend staffing, even though weekend schedules showed LPNs/CNAs on each shift, including call-ins and staff who picked up shifts. The NHA said PBJ reporting was handled by corporate with HR support, and the HR scheduler stated the facility does not use agency staff and that census or data entry errors may have affected the report.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with impaired cognition and significant physical care needs was able to leave the facility unsupervised by asking another resident to push their wheelchair to a store. After staff returned the resident, the facility did not reassess for elopement risk, update the care plan, or implement interventions to address the risk of future unsupervised departures or alcohol-seeking behaviors.
A facility failed to implement hospital physician orders for a resident readmitted after a hospital stay. The resident, who was severely cognitively impaired, did not receive a scheduled vitamin D blood test, and a follow-up urology appointment was delayed. Staff interviews revealed that hospital discharge orders were not properly transcribed or implemented, and the facility's policy did not address handling orders from another medical system.
A facility failed to implement a bowel program for a severely cognitively impaired resident who required substantial assistance with toileting. Despite physician orders for Senna and MiraLax, the resident did not have a recorded bowel movement for several days, and the bowel protocol was not administered. Interviews with staff revealed that the protocol was not followed, and documentation was inaccurate.
A facility failed to assess and address a resident's nutritional status after a significant weight gain and loss, which was later deemed an error. The resident's weight was inconsistently monitored, with no weights recorded for a month, and corrective actions were not taken. Staff interviews revealed that the resident was a good eater and not on diuretics, and the facility's outdated methods for recording weights contributed to the oversight.
The facility failed to implement its water management plan, resulting in a deficiency in infection prevention and control. The water heating system malfunctioned, leaving the facility without hot water for five days. During this time, the facility did not conduct water temperature testing or take corrective actions, increasing the risk of waterborne pathogens. The delay in contacting the contracted company and the lack of monitoring contributed to the deficiency.
The facility failed to provide sufficient nursing staff during night shifts, affecting the well-being of all 66 residents. A resident reported long wait times for assistance, and the facility was flagged for low weekend staffing. Staffing schedules showed multiple instances of inadequate staffing, with only one CNA or one licensed nurse scheduled despite a high census. The facility did not use agency staff to address shortages, and struggled to maintain adequate staffing levels.
The facility failed to maintain a hygienic environment in the 3rd floor shower room, which was used by all residents requiring showers due to the 2nd floor shower room being out of order. The room was cluttered with equipment and unclean items, including dirty washcloths and a dirty commode bucket. The shower area had standing water, a dripping shower pipe, and a floor covered with dirt and a slimy film. Staff were unaware of the extent of the uncleanliness, and the facility lacked a specific cleaning policy for shower rooms.
A resident with a Foley catheter was not properly managed according to physician and urologist orders in an LTC facility. Despite orders to clamp the catheter every four hours to develop bladder capacity, staff were unaware of the procedure, and it was not documented as performed. The MAR showed the procedure as completed, but there was no documentation of urine output or effectiveness. The DON acknowledged the issue, but no further information was provided to address the deficiency.
Failure to Provide Ordered Right-Hand Splint
Penalty
Summary
The facility did not ensure a resident with right-sided hemiplegia and a contracture of the right hand received the ordered treatment and services to maintain or improve range of motion and prevent further decrease in range of motion. The resident’s care plan included an intervention for a right-hand splint for contraction prevention, and the resident’s MDS indicated severe cognitive impairment, impairment in upper and lower extremity ROM on one side of the body, and dependence on staff for upper body dressing. However, the resident’s Visual/Bedside Kardex did not include application of a splint to the right hand. Surveyors observed the resident without a right-hand splint in place on two separate occasions. When asked, a CNA was unsure whether the resident needed a splint and then checked with an LPN, who stated the resident should have a splint in the right hand. The CNA reported being unable to find the splint, and the LPN then referred to the assignment sheet and instructed the CNA to use a towel for the resident’s right hand as indicated there. The NHA was informed of the concern and stated she would look into it, but expected the resident to have a splint in place if indicated.
Failure to Provide Proper Incontinence Care
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received the necessary services to maintain good personal hygiene. The resident had diagnoses including dementia, Alzheimer’s disease, and urinary retention, and the quarterly MDS indicated a BIMS score of 5, severe cognitive impairment. The resident was dependent on staff for toileting needs and was always incontinent of bowel and bladder. The care plan and Kardex directed staff to use disposable briefs, check and change every 2 to 3 hours, provide incontinence checks, and provide peri care. During observation, a hospice CNA was assisting the resident with incontinence care and the surveyor noted a strong urine smell, the resident was double briefed, and the briefs were completely soaked through to the chuck pad with urine. The surveyor asked an LPN if the resident should be double briefed, and the LPN stated that no one should be double briefed. The NHA later stated that double briefing is not allowed, is unacceptable, and is not something the facility endorses to promote good personal hygiene for residents or to assist with ADLs.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility did not ensure that it completed accurate mandatory submission of direct care staffing information based on payroll data in a uniform electronic format to CMS. Survey review of the PBJ Staffing Data Report for Fiscal Year 2025 showed excessively low weekend staffing for Quarter 2, and the surveyor compared that report with the facility’s weekend schedules for January 1 through March 31, 2025. Those schedules showed licensed nurses and CNAs present on each shift for each unit, including call-ins, agency staff, and staff who picked up shifts, and the surveyor noted there did not appear to be excessive call-ins. The surveyor also reviewed the facility assessment and compared it with the schedules provided, noting the facility consistently met staff ratios based on the assessment. When questioned, the NHA stated the PBJ report was completed by corporate with assistance from HR and that further review was needed to determine why the report triggered for low weekend staffing. The HR scheduler stated the facility does not use agency staff, prepares schedules 2 to 3 weeks in advance, posts open shifts in an electronic system, and is responsible for PBJ reporting; corporate sends a quarterly nursing coverage report and the facility corrects entries if something was entered wrong. The NHA later stated the census may have been wrong on certain days and that managers sometimes help with care in ways that may not be reflected in the PBJ report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Reassess and Care Plan After Resident Leaves Facility Unsupervised
Penalty
Summary
A deficiency occurred when a resident with diagnoses including type 2 diabetes with foot ulcer, peripheral vascular disease, anxiety disorder, and paraplegia, who had moderately impaired cognition, was able to leave the facility premises without staff knowledge or supervision. The resident, who required total assistance from two staff members for dressing, transferring, and repositioning, asked another resident to push their wheelchair to a store. Facility staff intervened and returned both residents to the facility. At the time of the incident, the resident's admission elopement risk assessment indicated no risk for elopement, and there was no activated power of attorney. Following the incident, the facility did not reassess the resident for elopement risk, did not evaluate the resident's ability to leave the facility unsupervised, and did not initiate or update the care plan to address the risk of the resident leaving the facility or seeking assistance from peers to do so. The facility's policy requires a systemic approach to monitoring and managing residents at risk for elopement, including assessment, care planning, and intervention, but these steps were not taken after the event. Additionally, there were no care plan interventions related to the resident's potential alcohol-seeking behaviors, which was a concern raised by staff.
Failure to Implement Hospital Physician Orders for Resident
Penalty
Summary
The facility failed to implement hospital physician orders for a resident who was readmitted after a hospital stay. The resident, who was severely cognitively impaired and had a legal guardian, was supposed to have a laboratory blood test for vitamin D levels as recommended by the hospital physician. However, there was no evidence in the resident's electronic medical records that this order was transcribed or carried out by the facility. Additionally, the facility did not follow up on a referral for a urology appointment for the resident, despite multiple mentions of the need for such an appointment in the skilled nursing facility progress notes. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, revealed that the hospital discharge orders were not properly transcribed or implemented upon the resident's readmission. The Director of Nursing admitted to an error in interpreting the hospital discharge summary, which led to the delay in scheduling the necessary urology appointment. The facility's policy on physician orders did not address the procedure for handling orders from another medical system, contributing to the oversight in the resident's care.
Failure to Implement Bowel Program for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement a bowel program for a resident who was severely cognitively impaired and required substantial assistance with toileting. The resident was admitted with physician orders for Senna and MiraLax to be administered as needed for constipation. However, the facility's documentation showed that the resident did not have a recorded bowel movement for several days in July, and the bowel protocol was not administered during these periods. Interviews with facility staff, including an LPN and the Director of Nursing, revealed that the bowel protocol was supposed to be initiated after three days without a bowel movement. The LPN confirmed that the orders were not implemented, and the DON acknowledged inaccuracies in the CNAs' documentation of the resident's bowel movements. This lack of accurate documentation and failure to follow the bowel protocol could lead to potential health issues for the resident.
Failure to Monitor and Address Nutritional Status
Penalty
Summary
The facility failed to properly assess and address the nutritional status of a resident after a significant weight gain and subsequent loss, which was later determined to be an error. The facility's policy required consistent monitoring of residents' weights and timely interventions for significant changes. However, the resident's weight was not consistently monitored, and there were no weights recorded for an entire month. Additionally, the facility did not take corrective action after identifying the weight gain and loss as an error. The resident in question was admitted with a weight of 159.2 pounds and was identified as being at risk for malnutrition. Despite this, the facility did not follow through with the physician's order to weigh the resident weekly for four weeks and then monthly. The resident experienced a significant weight fluctuation, with weights recorded as 159.2, 161.2, 152.0, 156.2, 173.0, 164.5, and finally 148.7 pounds over several months. The weight of 173.0 pounds was later crossed out as inaccurate, and the resident was reweighed at 164.5 pounds in his wheelchair, indicating a failure to subtract the wheelchair's weight initially. Interviews with staff revealed that the resident was a good eater and not on diuretics, which could explain weight changes. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) acknowledged the failure to re-weigh the resident when discrepancies were noted. The Registered Dietician (RD) also confirmed that the hospital weight was not reliable and that the quarterly assessment was completed by a subcontractor. The facility's administrator admitted that the staff was still using outdated methods for recording weights, contributing to the oversight.
Failure to Implement Water Management Plan
Penalty
Summary
The facility failed to implement its water management plan effectively, leading to a deficiency in infection prevention and control. The water heating system stopped working, leaving the facility without hot water for five days. During this period, the facility did not conduct water temperature testing or take corrective actions to address the potential growth of waterborne pathogens. This lapse in protocol had the potential to affect all 64 residents. The Nursing Home Administrator (NHA) was on vacation when the issue arose and was not informed until returning on August 12, 2024. The facility delayed contacting the contracted company to assess the problem, resulting in a further delay in restoring hot water. The contracted company was not made aware of the urgency and did not arrive until August 14, 2024, to address the issue. The facility's maintenance director was also unaware of the need for increased monitoring during the hot water outage, as temperatures were not recorded during this time. The facility's water management plan, which includes protocols for monitoring and maintaining water temperatures to prevent microbial growth, was not followed. The lack of hot water and the failure to monitor water temperatures increased the risk of waterborne pathogens, as the water system was not flushed or otherwise managed to mitigate this risk. The facility's inaction and delayed response contributed to the deficiency noted by the surveyor.
Inadequate Night Shift Staffing in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient nursing staff was provided to meet the needs of all residents, potentially affecting the well-being of all 66 residents at the time of the survey. During a resident council interview, a resident expressed concerns about the lack of staff during the night shift, describing it as a 'ghost town' and reporting instances where their call light went unanswered for almost an hour. This resident also expressed fear of incontinence due to delayed toileting assistance. The facility was flagged for low weekend staffing during the second fiscal quarter of 2024, indicating a pattern of insufficient staffing. The surveyor's review of the facility's staffing schedules revealed multiple instances where the night shift was inadequately staffed, with only one Certified Nurse Aide or one licensed nurse scheduled despite a facility census of over 60 residents. The facility's staffing plan, as outlined in their Facility Assessment Tool, was not adhered to, particularly during the night shifts. Interviews with the facility's scheduler revealed that staffing levels were determined by census, and the facility did not utilize agency staff to address shortages. Despite attempts to overstaff to anticipate call-ins, the facility struggled to maintain adequate staffing levels, particularly on the night shift.
Unhygienic Conditions in Shower Room
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, specifically in the shower rooms. The surveyor observed that the 2nd floor shower room was out of order, forcing all residents requiring showers to use the 3rd floor shower room, which was not maintained in a hygienic manner. The 3rd floor shower room was found to be cluttered with various equipment and unclean items, including dirty washcloths, empty bottles, and a dirty commode bucket. The shower area had standing water, a dripping shower pipe, and a floor covered with dirt, debris, and a slimy film. The room was also used for storage, which contributed to its unclean state. The facility lacked a specific policy and procedure for cleaning shower rooms, as evidenced by the absence of such documentation when requested by the surveyor. The staff, including a CNA and an RN, were unaware of the extent of the uncleanliness and clutter in the shower room. Maintenance staff acknowledged the issues but indicated that housekeeping was responsible for cleaning the area. Despite the maintenance staff's awareness of the problems, no immediate corrective actions were taken to address the cleanliness and safety concerns in the shower room.
Failure to Follow Catheter Management Orders
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter was properly assessed and managed according to physician and urologist orders. The resident, who has a history of transverse myelitis, neuromuscular dysfunction of the bladder, and paraplegia, was admitted with a Foley catheter. Despite orders from the urologist and physician to clamp the Foley catheter every four hours to help the resident develop bladder capacity, this procedure was not documented as being performed. The lack of documentation and awareness among staff about the order indicates a failure in communication and adherence to the care plan. The surveyor's investigation revealed that the staff, including the Unit Manager and LPNs, were unaware of the specific orders regarding the clamping of the catheter. The MAR indicated that the procedure was signed off as completed, yet there was no documentation of the resident's urine output or any indication that the procedure was effective. Interviews with staff members confirmed that they were not performing the ordered procedure, and there was no documentation to suggest that the procedure was not being done due to the resident experiencing spasms. The deficiency was further highlighted by the lack of communication with the urologist regarding the resident's condition and the failure to document any deviations from the prescribed care plan. The Director of Nursing acknowledged the issue but did not provide additional information to address the surveyor's concerns. This oversight in following and documenting the care plan for the resident's catheter management represents a significant lapse in the facility's responsibility to provide appropriate care and treatment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Milwaukee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mercy Health Services | 2.2 mi | ★★★★★ | 3 | 0 |
| St Ann Health And Rehabilitation Center | 2.6 mi | ★★★★★ | 11 | 0 |
| Lutheran Home | 2.9 mi | ★★★★★ | 0 | 0 |
| Jewish Home And Care Center | 3 mi | ★★★★★ | 22 | 3 |
| Aria At Mitchell Manor | 3.1 mi | ★★★★★ | 3 | 0 |
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