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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K1 | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D19 | E9 | F8 |
| Minimal | A· | B· | C1 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| May 21, 2026 | Fire safety | Fire Safety Standard | 7 | Potential harm | — | Open → |
| May 21, 2026 | Health | Health Complaint, Health Standard | 11 | Immediate jeopardy | — | Open → |
| Feb 12, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Dec 12, 2024 | Fire safety | Fire Safety Standard | 8 | Potential harm | — | Open → |
| Dec 12, 2024 | Health | Health Standard | 0 | No citations | — | Open → |
| Oct 25, 2023 | Fire safety | Fire Safety Standard | 7 | Potential harm | — | Open → |
| Oct 25, 2023 | Health | Health Standard | 4 | Potential harm | — | Open → |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K1 | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D19 | E9 | F8 |
| Minimal | A· | B· | C1 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| May 21, 2026 | F-0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies · Clinical care | K · Immediate jeopardy Pattern | Corrected Jun 16, 2026 | |
| May 21, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Jun 16, 2026 | |
| May 21, 2026 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
3 facilities in 2 states. CMS chain ID 868.
Chain average overall rating (CMS): 3.7
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Franciscan Sisters of Christian Charity Sponsored Ministries, Inc | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 1, 2024 |
| Philip Dougherty | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2015 |
| Dennis Ferger | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jan 4, 2000 |
| John Heindel | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Nov 15, 2021 |
| Ann Maher | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Nov 15, 2020 |
| Judeen Schulte | Individual |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| St Paul Elder Services, Inc 316 East 14th Street, Kaukauna, WI 54130 CCN 525617 | 105 | May 12, 2026 | 20 | — |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Maplewood Center 8615 W Beloit Rd, West Allis, WI 53227 CCN 525069SFF Candidate | 2 km | 150 | Aug 25, 2026 | 1205 IJ6 harm1 open | $303k | |
| Complete Care at Hales Corners 9449 W. Forest Home Ave., Hales Corners, WI 53130 CCN 525596 | 2.9 km | 62 | Feb 19, 2026 | 371 harm | $18k | |
| Greendale Park Nursing and Rehab 5404 W Loomis Rd, Greendale, WI 53129 CCN 525549 | 4.6 km | 105 | Jul 1, 2026 | 1291 IJ9 harm | $281k | |
| Resolve at West Allis Respiratory and Rehab 9047 W Greenfield Ave, West Allis, WI 53214 CCN 525108 | 4.8 km | 152 | Aug 4, 2026 | 811 IJ4 harm | $130k | |
| Complete Care at Southpointe 4500 W. Loomis Rd., Greenfield, WI 53220 CCN 525604 | 4.9 km | 174 | Mar 12, 2026 | 452 IJ2 harm3 open | — | |
| Lindengrove New Berlin 13755 W Fieldpointe Dr, New Berlin, WI 53151 CCN 525064 | 4.9 km | 110 | Jul 20, 2026 | 502 IJ3 harm | $100k | |
| Sunrise Health Services 3540 S 43rd St, Milwaukee, WI 53220 CCN 525493 | 4.9 km | 99 | Feb 25, 2026 | 593 IJ | $114k | |
| Aria at Mitchell Manor 5301 W Lincoln Ave, West Allis, WI 53219 CCN 525600 | 5.2 km | 50 | Jul 1, 2026 | 451 IJ | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 525327 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 525327 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety |
| E · Potential harm Pattern |
| Corrected Jun 12, 2026 |
| May 21, 2026 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 15, 2026 |
| May 21, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 11, 2026 |
| May 21, 2026 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 16, 2026 |
| May 21, 2026 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 11, 2026 |
| May 21, 2026 | K-0911 | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 16, 2026 |
| May 21, 2026 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 11, 2026 |
| May 21, 2026 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 16, 2026 | Complaint |
| May 21, 2026 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 16, 2026 |
| May 21, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 16, 2026 |
| May 21, 2026 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 16, 2026 |
| May 21, 2026 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 15, 2026 |
| May 21, 2026 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Jun 16, 2026 |
| May 21, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Jun 8, 2026 |
| May 21, 2026 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jun 12, 2026 |
| May 21, 2026 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected Jun 16, 2026 |
| Feb 12, 2026 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 12, 2026 | Complaint |
| Feb 12, 2026 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 12, 2026 | Complaint |
| Dec 12, 2024 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 24, 2024 |
| Dec 12, 2024 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 27, 2024 |
| Dec 12, 2024 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 7, 2025 |
| Dec 12, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Dec 27, 2024 |
| Dec 12, 2024 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 2, 2025 |
| Dec 12, 2024 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Dec 30, 2024 |
| Dec 12, 2024 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 3, 2025 |
| Dec 12, 2024 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 3, 2025 |
| Oct 25, 2023 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 9, 2023 |
| Oct 25, 2023 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 22, 2023 |
| Oct 25, 2023 | K-0911 | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 13, 2023 |
| Oct 25, 2023 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 14, 2023 |
| Oct 25, 2023 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 9, 2023 |
| Oct 25, 2023 | K-0919 | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 13, 2023 |
| Oct 25, 2023 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 22, 2023 |
| Oct 25, 2023 | F-0685 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 22, 2023 |
| Oct 25, 2023 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 22, 2023 |
| Oct 25, 2023 | F-0849 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Nov 22, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.03 (case-mix index 1.40).
| Corporate officer / director |
| CORPORATE OFFICER |
| not provided |
| Nov 1, 2009 |
| Steve Chang | Individual | Managing employee | CONTRACTED MANAGING EMPLOYEE | not provided | Sep 1, 2021 |
| Timothy Loch | Individual | Managing employee | CONTRACTED MANAGING EMPLOYEE | not provided | Apr 1, 2024 |
| Dennis Ferger | Individual | Managing employee | W-2 MANAGING EMPLOYEE | not provided | Aug 20, 1984 |
| Carly Loewus | Individual | Managing employee | W-2 MANAGING EMPLOYEE | not provided | May 18, 2020 |