Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 St Ann Health And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Document Wander Guards in Assessments and Care Planning A resident with dementia and anxiety, another resident with dementia and developmental/epileptic encephalopathy, and a third resident with Wernicke's encephalopathy and Alzheimer's disease all had wander guard anklets ordered and documented on TARs as functioning daily. However, quarterly safety evaluations and MDS assessments did not reflect the devices, and one resident's care plan lacked an elopement/wander guard focus. CNA and the DON/ADON confirmed the anklets were in use, but staff had not considered the wander guard an assistive device.
Dignity During Transfer: A resident with legal blindness, moderate cognitive impairment, and mobility limitations was transferred from the restroom to her room on a stand-to-sit device while her pants were around her ankles and she was exposed in only a brief. CNA confirmed the transfer occurred that way, and the DON stated residents should be fully dressed in common areas and that the situation was a dignity issue.
The facility failed to accurately code MDS assessments for three residents who wore wander guards and had physician orders for the devices. Each resident was observed with a wander guard in place, but the quarterly MDS assessments did not document a wander/elopement alarm. CNA and MDS staff confirmed the residents had wander guards, and the DON confirmed MDS accuracy is required using RAI Manual guidance.
Missing Care Plan for Elopement Risk and Wander Guard: A resident with vascular dementia, severe anxiety, and major depressive disorder was assessed as high risk for elopement and had a physician order for a wander guard on the right ankle with daily checks. Staff observed and confirmed the device was in use and documented its function and skin condition, but the care plan lacked any elopement or wander guard focus, and the DON verified no care plan had been in place since admission.
Nebulizer Mask Not Stored Properly A resident with COPD, lung cancer, and PRN nebulizer orders had a nebulizer mask left propped next to the machine instead of being stored in a dry, clean bag after use. Staff observed blue liquid still in the reservoir, and RN and DON interviews confirmed the mask was not stored per facility policy or NIH guidance for clean storage of nebulizer parts.
Medication error rates exceeded the 5% threshold when an RN gave a resident an incorrect Prozac dose and omitted an ordered furosemide dose. The resident had major depressive disorder and chronic diastolic CHF, and the MAR and med cards showed 19 oral pills should have been administered, but only 16 were prepared and given. The RN confirmed the underdosing, and the DON stated meds are to be administered as ordered and in accordance with the six rights of medication administration.
Surveyors observed CNAs standing over two dependent residents during meals and one CNA feeding both residents interchangeably, rather than providing individualized, seated assistance as required by facility policy. One resident had severe cognitive and physical impairments, including spastic hemiplegia, paraplegia, aphasia, and moderate protein-calorie malnutrition, and required max assist with eating. The other had encephalopathy, CKD, type 2 DM, adult failure to thrive, Alzheimer’s, dementia, depression, and anxiety, and was totally dependent on staff for eating. Despite care plans and care cards specifying one-on-one assistance, staff stood while feeding and alternated bites between the two residents, and later explained they did not see available seats, while the DON confirmed staff are expected to sit when feeding residents.
A resident with severe cognitive impairment and a history of frequent aggressive behaviors did not have a care plan addressing physical aggression or staff interventions until after an incident where the resident became combative during care, resulting in injury. The facility failed to proactively implement behavioral health interventions despite ongoing documented behaviors.
Surveyors found that food items in the kitchen were left uncovered, undated, and improperly labeled, with some items not stored according to policy. Staff failed to consistently monitor food temperatures before serving, particularly for potatoes and gravy, and a dietary aide was observed working without a required beard restraint. These deficiencies affected nearly all residents receiving food from the kitchen.
A resident's medication administration record was left open and visible on a computer screen in a common area when an RN walked away from the medication cart, allowing multiple people to pass by and potentially view the resident's protected health information. The resident, who has moderate cognitive impairment and multiple diagnoses, expressed discomfort about the breach of privacy.
A resident with multiple chronic conditions experienced a significant change in condition, including unresponsiveness and labored breathing. The RN on duty did not obtain vital signs or perform a comprehensive assessment before the resident was sent to the hospital, as the necessary equipment was not immediately accessible and the RN chose to remain with the resident. Facility documentation lacked vital sign records during the event, and there was no policy detailing nursing assessment expectations during such changes.
A resident reported a discrepancy between the meal served and the menu tray card, receiving a confetti cake instead of the listed chocolate peanut butter bar. The Food Service Director noted that the cook, who uses a translator, sometimes prepares different items, and substitutions are made without updating the posted menu. The facility's policy requires adherence to posted menus and prompt communication of deviations, which was not followed.
Failure to Document Wander Guards in Safety Evaluations, MDS Assessments, and One Care Plan
Penalty
Summary
The facility failed to ensure that quarterly safety evaluations and quarterly MDS assessments accurately documented the use of elopement-prevention devices for three residents, and it also failed to develop a care plan for one resident using a wander guard. R3 had diagnoses including vascular dementia with severe anxiety and major depressive disorder, was assessed as high risk for elopement, and had a physician order for a wander guard to the right ankle with daily function checks. Although the TAR documented the wander guard as functioning daily from May 2025 through March 2026 and the device was observed in place, the quarterly safety evaluation and quarterly MDS did not document the wander guard, and the care plan lacked a focus for elopement or wander guard. R8 was admitted with diagnoses including vascular dementia, major depressive disorder, and developmental and epileptic encephalopathy. R8 had a physician order for a wander guard to the left ankle with daily function checks, and the care plan documented a focus for elopement and wander guard placement with interventions to monitor functionality and skin assessment daily. However, the quarterly safety evaluation and quarterly MDS did not document the wander guard, while the TAR documented the device as functioning daily from August 2025 through March 2026. R45 had diagnoses including Wernicke's encephalopathy and Alzheimer's disease. R45's care plan documented elopement and wander guard placement, and the physician ordered a wander guard to the left ankle with daily function checks. The quarterly safety evaluation and quarterly MDS did not document the wander guard, although the TAR documented the device as functioning daily from January 2024 through March 2026. CNA 2 confirmed that R3, R8, and R45 wore wander guard anklets that activated the elevator alarm, and the DON and ADON verified that the quarterly assessments lacked documentation of the devices and confirmed the devices were in use; they also stated they had not considered a wander guard anklet as an assistive device.
Dignity During Transfer
Penalty
Summary
The facility failed to ensure that one resident was transferred in a dignified manner. R24 was admitted with diagnoses including legal blindness, mild cognitive impairment, major depressive disorder, muscle weakness, difficulty walking, and need for assistance with personal care. The quarterly MDS indicated a BIMS score of 9 out of 15, showing moderate cognitive impairment, and that the resident used a wheelchair and was dependent on staff for toilet hygiene. The care plan identified that R24 required minimum assistance of two staff members for toilet transfers using a stand-to-sit assistance device. During an observation, CNA1 transferred R24 from the restroom to the resident's room on a stand-to-sit device while R24's black pants were around her ankles, exposing her in only a brief during the transfer. CNA1 later confirmed that she transferred R24 in that manner and stated she should not have done so, explaining that she did it because the room was directly across the hall. The DON stated that no resident should be transferred in that manner and that residents should be fully dressed if they are in any common area, describing it as a dignity issue that should never happen. The facility policy on Resident Rights stated that care and treatment should be provided in a manner and environment that maintains or enhances dignity and respect.
Inaccurate MDS Coding for Residents With Wander Guards
Penalty
Summary
The facility failed to ensure accurate MDS assessments for three residents who had wander guards in place. R3 was admitted with vascular dementia with severe anxiety and major depressive disorder, and had a physician order for a wander guard to the right ankle with daily checks. R8 was admitted with vascular dementia, major depressive disorder, and developmental and epileptic encephalopathy, and had a physician order for a wander guard to the left ankle with daily checks. R45 was admitted with Wernicke's encephalopathy and Alzheimer's disease, and had a physician order for a wander guard to the left ankle with daily checks. Each resident's quarterly MDS assessment lacked documentation of the presence of a wander/elopement alarm, despite the orders and the devices being in use.
Missing Care Plan for Elopement Risk and Wander Guard
Penalty
Summary
The facility failed to ensure a care plan was developed for Resident 3 related to elopement risk and the use of a wander guard. Resident 3 was admitted on 05/07/25 with diagnoses including vascular dementia with severe anxiety and major depressive disorder. The elopement assessment documented the resident as high risk for elopement, and a physician order dated 05/13/25 directed that a wander guard be placed on the right ankle with daily function checks and notification to nursing if it malfunctioned. The quarterly MDS showed the BIMS could not be completed because the resident was rarely or never understood. Review of the care plan showed no documented care focus for elopement or the wander guard. An observation on 03/03/26 at 2:43 PM found the wander guard on the resident's right ankle. During interviews on 03/04/26, CNA 2 confirmed the resident wore the wander guard and that it activated the elevator alarm when the resident was near the elevator, and RN 1 verified the resident had a wander guard and that nursing documented skin condition under and functioning of the device. RN 1 also confirmed there was no care plan in place for elopement or the wander guard. The DON later verified the resident had worn the wander guard since admission in May 2025 and that no care plan had been in place.
Nebulizer Mask Not Stored in a Sanitary Manner
Penalty
Summary
Respiratory equipment was not stored in a sanitary manner for a resident with COPD, lung cancer, and an acquired absence of lung who had PRN oxygen therapy and an order for albuterol nebulizer treatments as needed for shortness of breath or wheezing. The resident was cognitively intact with a BIMS score of 15 out of 15. During an observation, the resident’s nebulizer mask was propped up next to the nebulizer machine, and the resident stated it was never stored in a bag and that the last treatment had been the night before. A later observation showed the nebulizer mask still propped up next to the machine with blue liquid in the reservoir. RN3 stated breathing treatment masks should be cleaned after use, rinsed, left to dry on a paper towel, and then stored in a bag once completely dry for infection control purposes, and confirmed the mask was not stored in anything and still had treatment solution in it. The DON and Infection Preventionist also stated the mask needed to be stored in a bag after it was cleaned and dried. The facility policy required nebulizer cups and mouthpieces to be stored in a zip lock bag once completely dry, and the NIH nebulizer instructions stated to store nebulizer parts in a dry, clean plastic storage bag.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
Medication error rates were not kept below 5 percent because a resident with major depressive disorder and chronic diastolic CHF did not receive medications in the correct dosage as ordered. The resident’s record showed an order for Prozac 30 mg by mouth daily and an order for furosemide 40 mg by mouth daily for edema. During a medication administration observation, an RN prepared and administered medications to the resident, but the number of oral pills given did not match the ordered doses. Review of the MAR and medication cards showed that the resident should have received 19 oral pills, but only 16 were prepared and administered. The RN later confirmed that only one 10 mg Prozac tablet was given instead of the ordered 30 mg dose, and that the furosemide 40 mg dose was not administered. The DON confirmed that medications are to be given in the correct dosage and according to all medication orders, and the facility policy required review of the MAR and adherence to the six rights of medication administration.
Failure to Maintain Dignified Mealtime Assistance for Dependent Residents
Penalty
Summary
The deficiency involves failure to ensure residents were treated with dignity and respect during mealtimes, as required by facility policy and residents’ rights. Surveyor observations on 2/11/26 showed CNAs standing over residents while feeding them and one CNA feeding two residents interchangeably at the same time, contrary to the facility’s expectation that staff sit when feeding residents and provide a relaxing, enjoyable mealtime environment. The facility’s Meal Supervision and Assistance guideline, revised 10/29/24, states that residents will be prepared for a well-balanced meal in a calm environment with adequate supervision and assistance to assure an enjoyable event, but this was not followed during the observed meals. One resident (R1) had significant functional and cognitive impairments, including spastic hemiplegia, paraplegia, aphasia, moderate protein-calorie malnutrition, colostomy status, and seizures. R1’s MDS dated 1/5/26 documented both short- and long-term memory impairment, severely impaired decision-making, and range of motion impairment in both upper and lower extremities, with dependence on staff for eating and other ADLs. R1’s care card and care plan directed that R1 receive maximum assist from one staff member for eating and noted that R1 does well with finger foods. Despite these needs and directives, surveyors observed CNAs standing while feeding R1 and one CNA alternating feeding between R1 and another resident during both breakfast and lunch. Another resident (R2) had diagnoses including encephalopathy, CKD, type 2 DM, adult failure to thrive, Alzheimer’s disease, dementia, depression, and anxiety disorder. R2’s MDS dated 12/4/25 showed both short- and long-term memory impairment, severely impaired decision-making, no ROM impairment, and total dependence on staff for eating and other ADLs. R2’s care card and care plan documented total dependence on one staff member for eating. During breakfast, surveyors observed R2 appearing to be sleeping with a bowl of eggs in front of them while the CNA attempted to wake them, and later the same CNA stood between R1 and R2, feeding both residents interchangeably. Similar standing and alternating feeding behavior was observed at lunch. When interviewed, the CNAs stated they were standing because they did not see any seats, and the DON confirmed that CNAs are expected to follow the care cards and to sit when feeding residents, acknowledging the surveyor’s concerns about the observed practices.
Failure to Address and Manage Resident Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a history of encephalopathy, epilepsy, hemiplegia, hemiparesis, unspecified moderate dementia with behavioral disturbance, anxiety disorder, and insomnia. The resident exhibited severe cognitive impairment and demonstrated frequent behavioral symptoms, including yelling, screaming, kicking, hitting, grabbing, and rejection of care over multiple days. Despite these ongoing behaviors, the facility did not initiate a care plan focus area addressing the potential for physical aggression or implement specific interventions to guide staff response until after a significant incident occurred. On one occasion, while a CNA was providing care, the resident became combative, resulting in the resident's head hitting the wall and sustaining a swollen right eye and a laceration above the eye. Prior to this incident, there were no documented interventions in the care plan instructing staff on how to respond to the resident's agitation or aggression. The care plan was only updated to include such interventions after the incident, indicating a lack of proactive measures to address known behavioral risks and ensure staff were adequately prepared to manage the resident's behaviors.
Food Storage, Temperature Monitoring, and Staff Hygiene Deficiencies
Penalty
Summary
Surveyors identified multiple failures in the facility's food storage and service practices affecting 46 of 48 residents who receive food from the kitchen. Observations in the main kitchen's freezers and coolers revealed several partially used food items, such as bags of vegetables, meats, bread, cheese, milk, and Jell-O cups, that were left uncovered, open to air, and undated. These items were not labeled with open or use-by dates as required by facility policy. Interviews with the Food Service Director and kitchen staff confirmed that it is the facility's practice to date food items upon opening, but this was not consistently followed. Additionally, a used whip cream squeeze bag was found with residue on the outside, and some food items were not properly covered. Further deficiencies were observed in food temperature monitoring and staff hygiene. During meal service, dietary staff did not take required temperatures on all food items, specifically failing to check the temperature of potatoes and gravy before serving them to residents. Staff interviews indicated a misunderstanding of which items required temperature checks. Additionally, a dietary aide was observed working in the main kitchen without a beard restraint, contrary to facility policy requiring hair restraints to prevent contamination. These actions and inactions demonstrate noncompliance with professional standards for food safety and hygiene.
Failure to Protect Resident's Medical Record Privacy
Penalty
Summary
A deficiency occurred when a registered nurse (RN) left a medication administration record (MAR) containing protected health information for a resident open and visible on a computer screen in a common area. The RN walked away from the medication cart and entered a resident's room to administer medications, leaving the computer unattended and out of the RN's line of sight. During this time, the MAR was displayed in full view, and four individuals walked by in close proximity to the screen, making the resident's personal and medical information accessible to unauthorized viewers. The resident involved had diagnoses including cerebral infarction, COPD, depression, and Alzheimer's disease, with a moderate cognitive impairment as indicated by a BIMS score of 12. The resident expressed concern when interviewed, stating that it would be very bothersome if their medical information was left open for others to see. The facility was unable to provide additional information explaining why the resident's medical record was not kept private and confidential during this incident.
Failure to Complete Comprehensive Assessment During Resident Change in Condition
Penalty
Summary
A deficiency occurred when a resident with a history of atrial fibrillation, morbid obesity, hypertension, and congestive heart failure experienced a change in condition and did not receive a comprehensive assessment. The resident initially complained of stomach pain and nausea during the night, which was reported to the RN by a CNA. The RN offered PRN medication, which the resident declined, and provided education and encouragement to increase fluid intake. Later, the CNA reported a rapid change in the resident's condition. Upon assessment, the RN found the resident unresponsive, with labored breathing and foaming at the mouth, but with a pulse present. The RN called 911 immediately but did not obtain vital signs at any point during the change in condition, as the necessary equipment was not immediately available and the RN chose not to leave the resident alone. The facility's documentation, including the SBAR evaluation, lacked any recorded vital signs for the resident during the event. Interviews with the RN confirmed that no vital signs were obtained, and the RN stated that the equipment was located down the hall. The facility did not have a policy outlining the specific expectations for nursing assessment during a change in condition, only a policy regarding notification of changes. The DON acknowledged the concern regarding the incomplete assessment.
Menu Discrepancy and Communication Issues in Meal Service
Penalty
Summary
The facility failed to ensure that menus were followed and served as posted, which affected the satisfaction of residents receiving meals. During an interview, a resident complained that the meal served did not match what was listed on the menu tray card. The resident, who was cognitively intact with a BIMS score of 15, pointed out that the dessert served was a confetti cake instead of the chocolate peanut butter bar listed on the menu. This discrepancy was confirmed by reviewing the menu for the day, which indeed listed a chocolate peanut butter bar. The Food Service Director explained that the cook, who does not speak English, uses a phone translator to understand recipes, but sometimes prepares different items. Additionally, the Food Service Director mentioned that substitutions are made when items are unavailable, but the posted menu is not always updated to reflect these changes. The facility's policy requires that menus be followed as posted and that any deviations be communicated promptly, with substitutions providing comparable nutritive value. However, this policy was not adhered to, leading to the deficiency.
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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 | 0.4 mi | ★★★★★ | 3 | 0 |
| Wheaton Franciscan Hc - Terrace At St Francis | 1.5 mi | ★★★★★ | 38 | 0 |
| Aria At Mitchell Manor | 1.9 mi | ★★★★★ | 3 | 0 |
| Sunrise Health Services | 2.3 mi | ★★★★★ | 1 | 0 |
| Milwaukee Health And Rehab | 2.6 mi | ★★★★★ | 14 | 0 |
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