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Lutheran Home

7500 W North Ave, Wauwatosa, WI 53213 · Non profit - Corporation · 160 certified beds · (414) 258-6170 Medicare & Medicaid certified

Call the home — (414) 258-6170 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
7120 W North Ave · (414) 475-9095 · Call to confirm hours
Pharmacy
2656 N Wauwatosa Ave · (414) 453-9630 · Call to confirm hours
Grocery
8616 W North Ave · (414) 456-9525 · Call to confirm hours
Park
6900 W North Ave · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.9%16.1%15.4%typical
Long-stay residents who lose too much weight6.7%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder3.0%2.1%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection5.0%2.7%2.0%worse
Long-stay residents with depressive symptoms1.6%5.7%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.6%3.3%3.3%better
Long-stay residents whose ability to walk worsened17.4%18.4%16.1%typical
Long-stay residents on antianxiety or hypnotic medication8.7%16.9%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers6.3%5.0%4.7%worse
Long-stay residents with worsening bladder/bowel control29.7%24.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table15.6%15.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.5%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine93.8%82.2%79.4%better
Short-stay residents rehospitalized after admission28.6%23.1%22.6%worse
Short-stay residents with an outpatient ER visit8.9%15.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.561.661.67typical
Long-stay outpatient ER visits per 1,000 resident days0.422.291.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

58.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 242 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.1%U.S. median 51.5%
Got home and stayed home
12.2%U.S. median 10.7%
Went back to hospital
61.0%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 61.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 95 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF58.1%CMS range 51.2–63.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.2%CMS range 8.9–15.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge61.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge46.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting95.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened8.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 3.4–9.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.99
RN hours/ resident / day
0.77
LPN hours/ resident / day
2.53
Aide hours/ resident / day
4.28
Total nurse hours/ resident / day
0.59
RN hoursweekends
37.4%
Total nursing turnover
24.1%
RN turnover

How full it usually is: this home is certified for 160 beds and averages 127.8 residents a day — about 80% occupied, or roughly 32 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.28 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.99 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.80 hrs/resident/day on weekends vs 4.48 on weekdays — 15% thinner on weekends. RN hours go from 1.15 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

10
deficiencies at the latest standard inspection (2025-06-10)
7
at the previous standard inspection (2024-03-14)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

20 citations, most serious first. The 11 most serious are shown; the remaining 9 are one tap away and print in full.

  • Actual harm · Gcited before2023-10-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, policy review and review of facility documents, the facility failed to ensure two (Residents (R)1 and R3), of ten sampled residents were free of accidents. Specifically, R1 fell to the floor while unsupervised and sustained a fracture requiring surgical intervention, and R3 fell to the floor while unsupervised which resulted in a head laceration requiring medical treatment. In addition, both R1 and R3 were not provided individual interventions on their care plans to prevent the falls from occurring. The failure to provide adequate supervision and individual fall risk interventions placed R1 and R3 at risk for falls with injury. Findings include: Review of the facility's policy titled Falls with a revision date 05/17/23 indicated Residents have the right to be mobile and free from physical restraints with minimal risk for injury. The goal is to reduce falls as much as possible, and to reduce the risk of serious injury . all residents will be assessed for their fall risk upon…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-10 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    3.) On 2/11/25, the nurses note indicates R54 was experiencing a change in condition and was sent to the hospital. The nurses note on 2/11/25 indicates R54 was being admitted to the facility due to influenza and needing dialysis. On 6/9/25 at 3:10 p.m., during the daily exit meeting with NHA(Nursing Home Administrator)-A and DON (Director of Nursing)-B, Surveyor asked for a copy of the transfer and bedhold notice given to R54 for the 2/11/25 hospitalization. On 6/10/25 Surveyor received the transfer and bedhold notice dated 2/12/25 for R54. The transfer and bedhold notice does not include email address for state agency and facility and does not include information regarding the Ombudsman and how to contact the ombudsman. On 6/10/25 at 10:45 a.m. Surveyor interviewed NHA-A. NHA-A stated she understood the concern and had no additional information. Based on record review and interview, the facility did not provide the required documentation with resident transfers to the hospital. This was observed with 4 (R22, R86, R54, and R77) of 5 resident hospitalization reviews. * R22, R86, R54,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-10 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility did not ensure each resident receives, and the facility provides food prepared by methods that conserve nutritional value, flavor, and appearance. This deficient practice had the potential to affect 8 residents receiving a puree diet. The recipe for preparing pureed diet was not followed to ensure puree food is prepared by methods that conserve nutritional value, flavor and appearance. Findings include: The facility policy and procedure titled General Food Preparation reviewed 6/2025 documents (in part) . . Policy Statement: All food must be prepared in a manner that maintains its safety, quality, and nutritional value. Proper food handling techniques must be followed at all times to prevent forborne illness and ensure resident satisfaction. 3. Special Diets and Resident Needs: Follow individualized dietary plans as ordered by the registered dietician or physician. Ensure consistency-modified diets (e.g., pureed, mechanical soft) are prepared correctly to reduce the risk of choking. 1.) On 6/5/25 at 9:00 AM, Surveyor…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 3 resident unit refrigerators in the facility. This deficient practice had the potential to affect 46 residents residing on the affected unit. Residents' food stored in the refrigerator was not labeled and/or dated. The refrigerator temperature was not within the recommended temperature for safe food storage. Findings include: The facility policy and procedure titled Food Storage-Resident reviewed 1/29/24 documents (in part) . Policy statement: All perishable food items brought in by family and visitors must be refrigerated and labeled. 1.0 Perishable food brought in by family or visitors will be labeled by nursing staff and refrigerated. 2.0 Labels will state residents name, date received/opened and discard date. 3.0 A food chart is maintained on each refrigerator indicating the discard date for each food item. Any questions regarding discard dates should be directed to Dining and Hospitality. 4.0…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-10 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not maintain an infection and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for 4 (R87, R12, R77 and R528) of 26 residents reviewed for Infection Control practices. * Surveyor observed Wound Medical Doctor (MD)-O, Nurse Manager-J, and Wound tech-P perform wound care for R87 without wearing proper Personal Protective Equipment (PPE). *Surveyor observed Certified Nursing Assistant (CNA)-K provide bowel incontinence care for R87 and did not change gloves and wash hands prior to performing peri care/catheter care. *Surveyor observed Advanced Practice Nurse Practitioner (APNP)- Q assess R87's right lower leg wound without proper PPE. *Surveyor observed Wound MD-O not wearing a glove while performing wound debridement for R12's wound care. *Surveyor observed PPE not worn while providing incontinence cares for R12. *PPE not used for R528…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-10 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not provide a comprehensive care plan for 1 (R96) of 5 residents reviewed for bowel and bladder incontinence. R96 is incontinent of bowel and bladder and did not have a comprehensive care plan for incontinence. Findings include: 1.) R96 was admitted to the facility on [DATE] with diagnoses that included Chronic Kidney Disease Stage 3, and Dysuria (pain with urination) On 6/5/25, R96's Annual Minimum Date Set (MDS) dated [DATE] was reviewed and indicated R96 was frequently incontinent of bladder. R96's brief interview for mental status on this assessment documented a score of 13 (cognitively intact). R96's MDS triggered for urinary incontinence and was selected to continue to care plan. R96's Care Area Assessment (CAA) for urinary incontinence dated 3/24/25 triggered and documented resident needing assistance with toileting including transfers, clothing adjustment and toileting hygiene. Resident is frequently incontinent of bladder. Staff provides…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 2 (R77, R87) of 26 residents needing assistance with Activities of Daily Living (ADL) cares, received the necessary services for cares. *R77 did not receive nail care per care plan, policy and resident's preference. *R87 did not receive scheduled shower per care plan and resident's preference. Findings include: The Facilities Policy titled, Standards of Care at Lutheran Home. Revised 6/1/2023. Documents: Policy Statement: Lutheran Home will provide routine interventions for all residents. These interventions do not to be addressed on the resident's individual care plan or care card. If the standard is different for a resident, the individual plan of care will reflect the variance. Standards: . Resident will receive a weekly shower or bath. Regular nail care provided as needed. 1) R77 was admitted on [DATE] with diagnosis of Type 2 diabetes mellitus with diabetic neuropathy, polyneuropathy, difficulty in walking, need for assistance with personal…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation, the facility did not ensure residents with pressure injuries received the necessary treatment and services, consistent with professional standards of practice, to promote hearling, prevent infection and prevent new ulcers from developing for 2 (R112 and R20) of 7 residents reviewed with pressure injuries. * R112 was transferred to the hospital with a pressure injury. Upon readmission, R112's pressure injury was not comprehensively assessed until 3 days later. R112 did not have a comprehensive plan of care related to a comprehensive assessment. *R20 developed a pressure injury in the facility that was not comprehensively assessed. The facility's policy and procedure titled Skin Care Program and dated 6/17/2019, documents: -The policy is for every resident who enters the facility will be evaluated within 8 hours to prevent the formation of pressure injuries. -Measuring Wounds As Follows: size, length, width, top of wound, depth and any undermining/tunneling;…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-10 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that 2 (R59 and R96) of 5 residents reviewed were provided pain management services consistent with professional standards of practice, including completing comprehensive assessment, developing a comprehensive person-centered care plan and evaluating the resident's goals and preferences. Findings include: On 6/9/25, the facilities policy and procedure titled Pain Management dated 1/16/19 was reviewed and documented: The 0-10 pain scale will be used for the alert resident. A pain data collection tool will be completed at a minimum on admission, readmission, quarterly and with any change of condition. The pain data tool will include: pain history, description of pain, non-pharmacological approaches that work for the resident. Location of pain, Resident's goal of pain management. Care plan is to include the residents underlying diagnosis or conditions that are causing or contributing to pain, residents goal for pain management, and pharmalogic and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-10 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, drugs used in the facility were not labeled in accordance with currently accepted professional principles, to include the expiration date when applicable for 2 of 2 medication rooms and 1 of 3 medication carts observed. Medication rooms and carts contained insulin that was expired, and insulin and eye drops that were not dated when opened. Findings include: The facility policy and procedure titled Medication and Vaccine Storage effective date [DATE] documents (in part) . . Policy statement: Medications will be stored safely, securely and properly. The medication supply will only be accessible to licensed nursing personnel, pharmacy personnel, and staff members authorized to pass medications. 5. Outdated or contaminated medications or those in cracked or soiled or without secure closures are removed from the medication cart and disposed of properly. Medications will be reordered as needed. 9. Medications will be stored in their original packing until ready for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure staff were trained to safely use a hoyer lift with support bars. This was observed with 1 (R2) of 1 residents using this type of Hoyer Lift. R2 obtained a bruise by their eye due to staff using the Hoyer Lift incorrectly. Findings include: The facility's policy and procedure, Safe Transfers, revision date of 7/1/2021. The Policy documents: Residents admitted to Lutheran Home will be assessed to ensure appropriate and recommended transfer techniques are in place to direct safe resident transfers. On 2/3/25, at 9:03 AM, Surveyor spoke with R2 in their room. R2 stated they had a bruise by their eye from the hoyer lift. R2 stated this happened on 12/28/24 and their eye still hurts. Surveyor reviewed R2's medical record. R2 is their own person. The most recent MDS (minimum data set) assessment is a Significant Change in Status completed 11/16/2024. This MDS documents R2 does not have any cognitive impairments and is dependent on staff for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 9 citations
  • Potential for harm · Fcited before2024-03-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review the facility did not ensure food was stored and served in accordance with professional standards for food safety. *Staff did not test Sentinel sanitizing solution per manufacturer's instructions when testing the sanitizing sink used for dishwashing. Staff did not log or document testing results. This affected 136 out of 136 residents who receive food prepared by the facility kitchen. *The Unit refrigerator on 2E had multiple food items that were not labeled with resident's name. Open food was not dated. The refrigerator was unclean. There was not a current temperature log posted on the refrigerator and temperatures were not being documented since December of 2023. This had the potential to affected 41 of 41 residents who can use the Resident's unit refrigerator on 2E. Findings include: 1.) On 3/12/24 at 10:53 AM, Surveyor toured the dishwashing area with the Dining and Hospitality Director (Director-L) and the Executive Chef (EC-K). Surveyor noted the facility's 3-compartment sink. Surveyor asked that the sanitizing sink be…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-14 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility did not ensure that food was prepared to conserve nutritive value. This has the potential to effect 8 of 8 residents on pureed diet. The Cooks Helper (CH-H) did not follow a recipe for preparing texture and modified consistency diet for pureed food. Findings include: The facility's policy and procedure, entitled SUBJECT: International Dysphagia Diet Standardization Initiative (IDDSI) Terminology for Food Textures and Drink Thickness, dated 11/21/2023, states: The [facility] will follow the IDDSI framework meant to provide a common terminology for describing food textures and drink thickness to improve safety for individuals with swallowing difficulties. Surveyor reviewed the IDDSI framework for preparing pureed food on the IDDSI website https://iddsi.org. Surveyor noted the IDDSI method includes testing the texture of the food before serving. IDDSI outlines the procedure for testing the food. For pureed food, IDDSI uses the fork test. Pureed food can be tested by assessing whether the food flows through the tines/prongs…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure 3 (R61, R66 & R63) of 5 sampled residents with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections and provide dignity for residents. *R61 was observed multiple times with their catheter drainage bag system uncovered and laying on the floor. *R66 was observed multiple times with their catheter drainage bag system uncovered. *R63 was observed multiple times with their catheter drainage bag system uncovered and with drainage system port uncovered directly on the floor. Findings include: 1. R61 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease stage 3, muscle weakness and sepsis. R61's admission MDS (Minimum Data Set) assessment dated [DATE] indicated R61 had moderately intact cognition with a BIMS (brief interview for mental status) score of 12. R61 was noted to require maximal assist with 1 person for incontinence cares. R61 requires use of a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. Licensed Practical Nurse (LPN) - E did not safely administer Insulin to 1 (R58) of 1 resident observed for insulin administration. Findings include: R58 was admitted to the facility 5/6/20 with diagnoses that included Alzheimer's Disease, Chronic Kidney Disease and Type 2 Diabetes Mellitus. Surveyor reviewed R58's MD orders. Documented with a start date of 12/12/23 and an administration time of 7:00 AM to 10:00 AM was Novolin 70/30 U-100 Insulin (insulin ph and regular human) [OTC] suspension; 100 unit/mL (70-30); amt: Per Sliding Scale; If Blood sugar is less than 70, call NP/PA. If Blood Sugar is 71 to 100, give 20 Units. If Blood Sugar is 101 to 400, give 30 Units. If Blood Sugar is greater than 400, call NP/PA. subcutaneous Special Instructions: BREAKFAST [DX: Type 2 diabetes mellitus with diabetic chronic kidney…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure proper antibiotic use for 1 (R46) of 4 resident's reviewed for antibiotic use. *R46 was prescribed an antibiotic prior to obtaining a respiratory panel. Results of the respiratory panel documented R46 was infected with the para-influenza virus, which does respond to antibiotics. Findings: POLICY STATEMENT: [name of the facility], in conjunction with the medical director, consultant pharmacist, and administration will promote effective management and utilization of antibiotics prescribed to residents. This policy provides guidelines for the healthcare staff caring for our older adults, to recognize infection and initiate appropriate evaluation and treatment in a timely fashion, thereby improving outcomes of care. The [name of the facility] will utilize McGeer's [sic] definitions as one of the surveillance tool for infection tracking. Older adults who symptoms do not meet the guidelines for an infection should receive an intervention aimed at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure that its medication error rate was not 5 percent or greater. During observation of medication administration, the facility staff made medication errors with 2 (R58 and R10) of 7 residents observed for medication administration for a total of 2 errors of 31 opportunities for an error rate of 6.45%. ~ R58 was administered Novolin insulin that was expired. ~ R10 was administered Aspirin where the expiration date was illegible and was unable to be confirmed if it was expired or not. Findings include: Surveyor reviewed Medication and Vaccine Storage policy with an effective date of [DATE]. Documented was: .5. Outdated or contaminated medications or those in cracked or soiled or without secure closures are removed from the medication cart and disposed of properly. Medications will be reordered as needed . 11. Insulin is to be refrigerated until opened. Once open, insulin can remain at room temperature until expiration, based on guidelines…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-14 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review and observation, the facility did not assure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles and include the expiration date when applicable in 3 of 3 Medication Carts and 2 of 2 Medication Storage Rooms reviewed for compliance. Surveyor observed undated, opened eye drops in 2NW Cart 1. Surveyor observed undated and unlabeled medications in 2NW Cart 1. Surveyor observed insulin that should have been refrigerated in 2NW Cart 1. Surveyor observed expired insulin in 2NW Cart 1. Surveyor observed 2 medications stored in latex gloves in 2NW Medication Room. Surveyor observed a salad in the medication fridge in the 2NW Medication Room. Surveyor observed nose spray with no opened on date in 3NW Cart 1. Surveyor observed 2 unlabeled tubes of ointment in the same container in 3NW Cart 1. Surveyor observed undated, opened eye drops in 3NW Cart 1. Surveyor observed undated and unlabeled medications in 3NW Cart 1. Surveyor observed expired eye drops in 3NW Cart 1. Findings include:…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-19 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, policy review and review of facility event reports, the facility failed to develop a baseline care plan to include individual approaches and interventions to prevent a fall for one (Resident (R) R1) of 10 sampled residents. Specifically, R1 fell to the floor while unsupervised which resulted in R1 sustaining a fracture requiring surgical intervention. Findings include: Review of the policy titled Falls with a revision date 05/17/23 indicated Residents have the right to be mobile and free from physical restraints with minimal risk for injury. The goal is to reduce falls as much as possible, and to reduce the risk of serious injury . all residents will be assessed for their fall risk upon admission . risk factors will be identified . interdisciplinary interventions will be identified and included on the plan of care. Review of R1's Face Sheet located in the Electronic Medical Record (EMR) under the Resident tab indicated R1 was admitted on [DATE] with diagnoses including…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-06-10 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure assessments accurately reflected residents' status for 4 (R55, R59, R52, and R14) of 4 reviewed for Preadmission Screening and Resident Review (PASRR) with serious mental illness diagnosis. *R55, R59, R52, and R514 had PASRR Level I and Level II completed, and had diagnosis of serious mental illnesses, but this was not documented into the Minimum Data Set (MDS) comprehensive assessment at section A1500. Findings include: 1.) R55 was admitted to the facility on [DATE] with diagnoses of major depression, auditory and visual hallucinations, and anxiety. On 6/9/25, R55's Annual Minimum Data Set (MDS) dated 11/6//24 section A1500 documented R55 does not have a serious mental illness. Section I labeled active diagnosis documented R59 has diagnosis of anxiety, depression, and psychotic disorder. This MDS was completed by Social Worker-T. On 6/9/25, R55's preadmission screen and resident review (PASRR) level 1 screen dated 8/25/20 indicates R55 has a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
DENOR, JIMIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 04/01/2021
EHN, DIANEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICERsince 10/01/2021
HODAN, MIKEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 04/01/2023
KEBBEKUS, BENIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 04/01/2021
KRIETE, LINDSEYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 04/01/2023
MUELLER, GARYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 04/01/2021
PEDERSEN, HARRIETIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 04/01/2018
RAASCH, RANDYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 04/01/2023
REARDON, TIMIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 10/01/2019
ROSENBERG, PAULIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 10/01/2021
SANDSTROM, DAVIDIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICERsince 10/01/2021
SURMA, KRISTINAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICERsince 10/01/2021
TRISKA WIEMER, KATIEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 04/01/2023
PINGEL, LINDSAYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/21/2025
CAVERS, KATHRYNIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2012
CLAUSEN, HENRIKIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/17/2021
BUKOWY, ELIZABETHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/20/2014
SWARTZ BARTLETT, CAREYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2014
TETTENBORN, JAYNEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/14/2021
SEASONS HOSPICE & PALLIATIVE CARE OF WISCONSIN, LLCOrganizationADP OF THE SNFsince 07/15/2025
WIPFLI LLPOrganizationADP OF THE SNFsince 04/29/2014

CMS files one row per role, so the 46 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$25.0M
Net patient revenuemost recent cost report
-10.7%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 39%Medicare 5%Other / private 56%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$391per resident / day
operating cost
$11,875per month
≈ monthly operating cost
$353per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WI

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.

Typical monthly cost in Wisconsin
$10,646/mo
Nursing home (semi-private)
$12,319/mo
Nursing home (private)
$6,540/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525545. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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