Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Camillus Health Center during CMS and state inspections, most recent first.
Two residents with significant cognitive and physical impairments experienced incidents involving suspected abuse and an injury of unknown origin. In both cases, the facility failed to report the events to law enforcement and the state agency within the required timeframes, despite internal investigations and clear policy requirements for immediate reporting.
Two residents experienced harm due to the facility's failure to assess and assign appropriate slings for mechanical lift transfers and to develop individualized fall prevention plans. Staff used unassessed or incorrectly sized slings, leading to a serious fall and head injury for one resident, while another resident suffered multiple falls and injuries due to lack of supervision and care planning. Slings were not consistently labeled or matched to residents, and staff often relied on assumptions rather than documented assessments, resulting in unsafe transfer practices and inadequate accident prevention.
Multiple failures in infection prevention and control were identified, including the absence of a comprehensive water management plan, improper use of PPE and hand hygiene during resident care, and lack of Enhanced Barrier Precautions for residents with open wounds or medical devices. Staff were observed administering medications and performing wound care without required gowns or consistent hand hygiene, and there was confusion among staff regarding EBP requirements.
The facility did not perform regular inspections of bed rails for several residents who used bilateral enabler bars or quarter side rails, despite having a policy requiring routine checks for safety and entrapment risks. Staff reported that bed rails were only checked when a work order was received or as needed, rather than as part of a scheduled maintenance program. Observations confirmed that multiple residents had bed rails in use without evidence of regular inspection.
The facility did not complete required quarterly assessments or obtain updated informed consent for bed rail use for two residents with cognitive and mobility impairments. Both residents had repositioning bars in use without current documentation, care plan interventions, or physician orders as required by facility policy. Staff confirmed that assessments and consents were not consistently performed.
A resident with severe cognitive impairment and multiple medical conditions reported three separate incidents of sexual abuse. The facility's investigations did not include interviews with the resident's roommate or all relevant staff, and used generic questions unrelated to the specific allegations. As a result, the investigations were incomplete and did not meet the facility's policy requirements.
Failure to Timely Report Suspected Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse and injuries of unknown origin for two residents. In the first case, a companion of a resident overheard a CNA speaking to the resident in a stern and demanding voice, telling the resident to stop crying and to pay attention, which caused the resident to become tearful, upset, and anxious. The companion observed the CNA yanking the resident's shirt off and reported the incident to the resident's daughter, who then notified the DON. Although the facility initiated an internal investigation and reported the incident to the state agency, they did not notify law enforcement as required by policy and federal regulations. In the second case, the facility was informed by a resident's wife of bruising and swelling of unknown origin on the resident's right foot. An X-ray revealed a fracture of the 5th metatarsal. The RN Supervisor did not notify the Nursing Home Administrator of the injury until three days after the incident, and the facility failed to report this significant injury of unknown origin to the State Agency within the required 24-hour timeframe. The facility's policy and federal requirements mandate immediate reporting of such incidents to both the state agency and law enforcement, especially when abuse or serious bodily injury is suspected. Both incidents involved residents with significant medical and cognitive impairments, including severe cognitive impairment, muscle weakness, and dependence on staff for activities of daily living. The facility's failure to follow established reporting protocols for suspected abuse and injuries of unknown origin resulted in noncompliance with federal and state regulations, as well as the facility's own policies.
Failure to Ensure Safe Use of Mechanical Lifts and Individualized Fall Prevention
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and appropriate assistive devices to prevent accidents, specifically in the use of mechanical lifts and slings for transfers. For one resident, staff used a sling brought in by the family without assessing its appropriateness for the resident's size, weight, or compatibility with the facility's Hoyer lift. During a transfer, the resident slid out of the unassessed sling and fell, sustaining a subdural hematoma and a laceration to the back of the head, which required hospital treatment and staples. Staff interviews revealed that they were unfamiliar with the manufacturer's recommendations for sling use and did not verify sling compatibility or sizing before use. There was no system in place to ensure that slings were assigned, labeled, or matched to individual residents, and staff often assumed that any sling found in a resident's room was appropriate for use. Another resident experienced multiple falls, including one resulting in multiple rib fractures after being left unattended during personal hygiene. The facility did not analyze the details of each fall or develop an individualized, comprehensive plan of care to prevent future incidents. Despite the resident's known incontinence and impulsivity, the facility did not complete a voiding pattern assessment or review the need for increased supervision, even after staff suggested it post-fall. The lack of individualized assessment and care planning contributed to repeated accidents and injuries. Observations during the survey found that slings were not consistently labeled with resident names or sizes, and staff frequently used slings interchangeably among residents without verifying appropriateness. Staff relied on assumptions or visual cues rather than documented assessments to select slings, and there was no clear documentation or quick-reference information available to guide staff in choosing the correct sling for each resident. The facility's failure to implement a system for assessing, assigning, and documenting appropriate sling use, as well as its failure to analyze and address fall risks, resulted in actual harm to residents and created a pattern of unsafe practices.
Infection Control Program Deficiencies: Water Management, PPE, and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program, as evidenced by multiple deficiencies in water management, use of personal protective equipment (PPE), hand hygiene, and implementation of Enhanced Barrier Precautions (EBP). The facility did not have a current, comprehensive water management plan that included a complete team, facility-specific flow diagrams, or identification of risk areas and interventions to prevent the spread of opportunistic pathogens such as Legionella. Interviews with staff revealed a lack of understanding of the water management program, incomplete documentation, and absence of risk area identification on facility maps. Daily water temperature logs were maintained, but other critical elements of the water management program were missing or not clearly communicated among team members. Observations of staff providing care to residents revealed repeated failures to use proper PPE and adhere to EBP protocols. For a resident with a gastrostomy tube, staff were observed administering medications and providing care without wearing required gowns and, at times, without gloves. Hand hygiene was inconsistently performed before donning gloves or after removing them, and staff were seen reusing gloves or failing to change them between tasks. These lapses occurred despite clear signage and care plans indicating the need for EBP due to the presence of a gastrostomy tube. Similar failures were observed during wound care for another resident with an open pressure injury, where staff did not use gowns as required and did not consistently perform hand hygiene at appropriate times. Additionally, a resident with a stage 2 pressure wound was not placed on EBP as required, and staff performed wound care using only gloves without gowns. During wound treatments, staff were observed handling clean and soiled items without performing hand hygiene in between, and contaminated items were placed in clean bins before handwashing. Interviews with staff indicated a lack of understanding regarding the need for EBP for open pressure injuries. These deficiencies were directly observed by surveyors and confirmed through interviews and record reviews.
Failure to Conduct Regular Bed Rail Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed rails as part of its maintenance program, as required by its own policy. The Environmental Services Director (ESD) reported that bed rails were only checked when a work order was received for installation or on an as-needed basis, rather than as part of a routine inspection schedule. This lack of regular inspection was confirmed during interviews and observations conducted by surveyors. Four residents were identified as having bilateral enabler bars or quarter side rails on their beds, but there was no evidence that these bed rails had been regularly inspected for safety or potential entrapment risks. For example, one resident had physician orders and care plans indicating the use of assist rails for skin integrity and bed mobility, while another had a side rail evaluation and verbal consent for repositioning bars, but no ongoing re-evaluation or documented inspections. Observations during the survey confirmed the presence of these devices on the residents' beds. The facility's policy requires regular inspection and maintenance of bed rails and mattresses to ensure safety and prevent entrapment, with responsibility assigned to the maintenance director or designee. Despite this, interviews with facility leadership and staff revealed that these inspections were not being performed as required, and no additional information or documentation was provided to demonstrate compliance with the policy.
Failure to Complete Required Bed Rail Assessments and Obtain Informed Consent
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the assessment, documentation, and consent for the use of bed rails for two residents. Both residents had significant cognitive impairments and required substantial assistance with mobility and transfers. The facility's policy requires a comprehensive assessment of the resident's needs and risks, including the risk of entrapment, as well as a review of risks and benefits with the resident or their representative, and obtaining informed consent prior to the use of bed rails. These steps must be repeated at least quarterly or upon significant change in status. For one resident, the facility did not document the use of side rails on the Minimum Data Set (MDS), despite physician orders and care documentation indicating the use of assist rails for skin integrity and fall risk. The treatment administration record showed inconsistent completion of the intervention, and the care plan did not specifically address the need for repositioning bars. Although a side rail evaluation and verbal consent were obtained the previous year, there was no evidence of informed consent or re-evaluation at the most recent quarterly assessment. For the second resident, there was no current physician order for the use of repositioning bars, and the use of side rails was not documented on the MDS. The resident was identified as high risk for falls, with a history of falls and significant cognitive and physical impairments. The side rail evaluation and verbal consent were completed at admission, but no quarterly re-evaluation or updated consent was documented. Staff interviews confirmed that the residents did not use the repositioning bars independently, and the DON acknowledged that quarterly assessments and consents were not consistently completed as required by policy.
Failure to Thoroughly Investigate Sexual Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate three separate allegations of sexual misconduct involving a resident with severe cognitive impairment and multiple medical conditions, including dementia, Alzheimer's disease, and major depressive disorder. The resident, who is dependent for daily activities and has an activated Health Care Power of Attorney, reported incidents of sexual abuse on three occasions. Despite the facility's policy requiring prompt and comprehensive investigations, the investigations conducted did not include all necessary interviews or relevant questions specific to the allegations. In each case, the facility interviewed a standard sample of five residents using generic questions about rough treatment, feeling rushed, or staff frustration, none of which directly addressed the nature of the sexual abuse allegations. The resident's roommate, who could have been a key witness, was not interviewed for two of the incidents. Additionally, in one incident where a male staff member was present during the alleged event, no statement was obtained from him. The facility also failed to document whether any men were in the building at the time of one of the reported incidents. Interviews with facility leadership revealed that the investigation process was based on sampling rather than targeting individuals directly involved or potentially knowledgeable about the incidents. The Director of Social Services and the Nursing Home Administrator confirmed that their process did not require interviewing roommates or all relevant staff, and that the same set of unrelated questions was used for all resident interviews. This approach resulted in incomplete investigations that did not meet the facility's own policy requirements for abuse allegations.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wauwatosa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Resolve At West Allis Respiratory And Rehab | 1.7 mi | ★★★★★ | 24 | 0 |
| Lutheran Home | 2.3 mi | ★★★★★ | 0 | 0 |
| St. Anne's Salvatorian Campus | 3.3 mi | ★★★★★ | 2 | 0 |
| Congregational Home, Inc. | 3.4 mi | ★★★★★ | 0 | 0 |
| Maplewood Center | 3.5 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.