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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D38 | E10 | F10 |
| Minimal | A· | B· | C2 |
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 20, 2026 | Fire safety | Fire Safety Standard | 7 | Potential harm | — | Open → |
| May 20, 2026 | Health | Health Standard | 2 | Potential harm | — | Open → |
| Apr 22, 2026 | Health | Health Complaint | 4 | Actual harm | — | Open → |
| Jan 21, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jul 31, 2025 | Health | Health Complaint | 3 | Immediate jeopardy | — | Open → |
| Jun 10, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 26, 2025 | Fire safety | Fire Safety Standard | 5 | Potential harm | — | Open → |
| Feb 26, 2025 | Health | Health Standard | 7 | Potential harm | — | Open → |
| Jan 9, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Oct 28, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| May 29, 2024 | Health | Health Complaint | 5 | Potential harm | — | Open → |
| Apr 23, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Feb 28, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Dec 13, 2023 | Fire safety | Fire Safety Standard | 7 | Potential harm | — | Open → |
| Dec 13, 2023 | Health | Health Standard | 10 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Jul 31, 2025 | Civil money penalty (fine) | $8,281 | — | 525668|Fine|139320 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D38 | E10 | F10 |
| Minimal | A· | B· | C2 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| May 20, 2026 | E-0009 | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 25, 2026 | |
| May 20, 2026 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 25, 2026 | |
| May 20, 2026 | K-0353 |
“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.
15 facilities in 7 states. CMS chain ID 315.
Chain average overall rating (CMS): 4.6
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Lifespace Communities Inc | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Apr 16, 2021 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Lifespace Communities Inc | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Apr 16, 2021 |
| Lifespace Communities Inc | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 16, 2021 |
| Jesse Jantzen | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 16, 2021 |
| Jesse Jantzen | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Apr 16, 2021 |
Coordinates as published by CMS (geocoding footnote 22).
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Avina of Milwaukee 9255 N 76th St, Milwaukee, WI 53223 CCN 525523Abuse icon | 5.8 km | 108 | Aug 12, 2026 | 1221 IJ5 harm | $142k | |
| Amethyst Health of Brown Deer 7500 W Dean Rd, Milwaukee, WI 53223 CCN 525498SFF Candidate | 7.1 km | 87 | May 20, 2026 | 1163 IJ4 harm1 open | $331k | |
| Bradley Estates Nursing and Rehab LLC 6735 W Bradley Rd, Milwaukee, WI 53223 CCN 525325SFF CandidateAbuse icon | 7.4 km | 198 | Jul 9, 2026 | 1903 IJ11 harm | $305k | |
| Complete Care at Glendale West 6263 N Green Bay Ave, Glendale, WI 53209 CCN 525547 | 10.1 km | 94 | Nov 12, 2025 | 651 IJ1 harm | $11k | |
| Bayshore Nursing & Rehab 1300 West Silver Spring Dr, Glendale, WI 53209 CCN 525371SFF CandidateAbuse icon | 11.6 km | 112 | Apr 30, 2026 | 1797 IJ3 harm1 open | $424k | |
| Lasata Care Center W76 N677 Wauwatosa Rd, Cedarburg, WI 53012 CCN 525537 | 12.7 km | 106 | Jan 7, 2026 | 37 | — | |
| Cedarburg Health Services N27 W5707 Lincoln Blvd, Cedarburg, WI 53012 CCN 525578 | 12.7 km | 50 | Apr 29, 2026 | 36 | — | |
| Luther Manor 4545 N 92nd St, Milwaukee, WI 53225 CCN 525588 | 14.7 km | 99 | Jul 29, 2026 | 853 IJ4 harm1 open | $164k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 525668 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 525668 | 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
| Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety |
| F · Potential harm Widespread |
| Corrected Jun 15, 2026 |
| May 20, 2026 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 15, 2026 |
| May 20, 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 15, 2026 |
| May 20, 2026 | K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 15, 2026 |
| May 20, 2026 | 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 Jun 15, 2026 |
| May 20, 2026 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Jun 15, 2026 |
| May 20, 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 15, 2026 |
| Apr 22, 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 May 13, 2026 | Complaint |
| Apr 22, 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 May 13, 2026 | Complaint |
| Apr 22, 2026 | F-0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 13, 2026 | Complaint |
| Apr 22, 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 May 13, 2026 | Complaint |
| Jan 21, 2026 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 23, 2026 | Complaint |
| Jan 21, 2026 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 23, 2026 | Complaint |
| Jul 31, 2025 | 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 | J · Immediate jeopardy Isolated | Corrected Aug 1, 2025 | Complaint |
| Jul 31, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 1, 2025 | Complaint |
| Jul 31, 2025 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 1, 2025 | Complaint |
| Jun 10, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 10, 2025 | Complaint |
| Feb 26, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 12, 2025 |
| Feb 26, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 21, 2025 |
| Feb 26, 2025 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 12, 2025 |
| Feb 26, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 21, 2025 |
| Feb 26, 2025 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 4, 2025 |
| Feb 26, 2025 | 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 Apr 4, 2025 |
| Feb 26, 2025 | 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 | D · Potential harm Isolated | Corrected Apr 4, 2025 |
| Feb 26, 2025 | F-0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 4, 2025 |
| Feb 26, 2025 | 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 Apr 4, 2025 |
| Feb 26, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 4, 2025 |
| Feb 26, 2025 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Apr 4, 2025 |
| Feb 26, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Apr 8, 2025 |
| Jan 9, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 7, 2025 | Complaint |
| Jan 9, 2025 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 7, 2025 | Complaint |
| Oct 28, 2024 | 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 Nov 26, 2024 | Complaint |
| Oct 28, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Nov 26, 2024 | Complaint |
| May 29, 2024 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 25, 2024 | Complaint |
| May 29, 2024 | 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 25, 2024 | Complaint |
| May 29, 2024 | 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 | D · Potential harm Isolated | Corrected Jun 25, 2024 | Complaint |
| May 29, 2024 | 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 Jun 25, 2024 | Complaint |
| May 29, 2024 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 25, 2024 | Complaint |
| Apr 23, 2024 | 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 May 23, 2024 | Complaint |
| Apr 23, 2024 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 23, 2024 | Complaint |
| Apr 23, 2024 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 23, 2024 | Complaint |
| Feb 28, 2024 | F-0626 | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 30, 2024 | Complaint |
| Feb 28, 2024 | F-0740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 30, 2024 | Complaint |
| Dec 13, 2023 | E-0009 | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Dec 15, 2023 |
| Dec 13, 2023 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 5, 2024 |
| Dec 13, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 15, 2023 |
| Dec 13, 2023 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 15, 2023 |
| Dec 13, 2023 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 1, 2024 |
| Dec 13, 2023 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 28, 2023 |
| Dec 13, 2023 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 5, 2024 |
| Dec 13, 2023 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 5, 2024 |
| Dec 13, 2023 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 5, 2024 |
| Dec 13, 2023 | F-0625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 5, 2024 |
| Dec 13, 2023 | 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 | D · Potential harm Isolated | Corrected Jan 5, 2024 |
| Dec 13, 2023 | 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 Jan 5, 2024 |
| Dec 13, 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 Jan 5, 2024 |
| Dec 13, 2023 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Jan 5, 2024 |
| Dec 13, 2023 | 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 Jan 5, 2024 |
| Dec 13, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jan 5, 2024 |
| Dec 13, 2023 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Dec 28, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 5.26 (case-mix index 1.39).
| Joseph Gorman | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jul 11, 2022 |
| Nicholas Harshfield | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Apr 16, 2021 |
| Jesse Jantzen | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Apr 16, 2021 |
| Erin Pope | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jul 25, 2022 |
| Christy Stemm | Individual | Managing employee | W-2 MANAGING EMPLOYEE | not provided | Jul 1, 2021 |