Your report for Avina of Milwaukee
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- WisconsinLowest tier among peers321 rated homes · average 3.0★
- Milwaukee CountyLowest tier among peers32 rated homes · average 2.4★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs WI avg
- StaffingCan add or remove a star1★−2.7 vs WI avg
- Quality measuresCan add or remove a star3★−0.1 vs WI avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersWI avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersWI avg3.7★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 33% of peersWI avg3.1★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff2.87hrsAbove only 2% of peersWI avg4.19Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.61hrsAbove only 14% of peersWI avg0.96Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better—No dataWI avg48%RN turnover—
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$90,921Above only 17% of peersWI avg$41,875Fines · denials2 · 2
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthApr 2022 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 4, 2025Cycle 1worst D · no actual harm
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected Jan 4, 2026
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Jan 4, 2026
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jan 4, 2026
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Jan 4, 2026
Jul 28, 2025Cycle 1worst D · no actual harm
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 28, 2025
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Sep 18, 2025
Mar 20, 2025Cycle 1worst E · no actual harm
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Apr 20, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 20, 2025
- F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Apr 20, 2025
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 20, 2025
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 20, 2025
Dec 3, 2024Cycle 2worst E · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Dec 20, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 20, 2024
Oct 7, 2024Cycle 1worst G · actual harm$74,120, payment denial
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Nov 5, 2024
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Nov 5, 2024
- F656Develop 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 PlanningD · isolatedCorrected Nov 5, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Nov 5, 2024
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Nov 5, 2024
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Nov 5, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Nov 5, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Nov 5, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Nov 5, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 20, 2024
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 5, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Dec 20, 2024
Jul 1, 2024Cycle 2worst J · immediate jeopardy$16,801, payment denial
- F946Provide training in compliance and ethics.AdministrationF · widespreadCorrected Aug 6, 2024
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesE · patternCorrected Aug 6, 2024
- F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.AdministrationF · widespreadCorrected Aug 6, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareJ · isolatedCorrected Aug 21, 2024
- F583Keep residents' personal and medical records private and confidential.Resident RightsE · patternCorrected Aug 6, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 6, 2024
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 6, 2024
- F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Aug 6, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Aug 6, 2024
- F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesF · widespreadCorrected Aug 6, 2024
- F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareD · isolatedCorrected Aug 6, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Aug 6, 2024
- F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Infection ControlD · isolatedCorrected Aug 6, 2024
- F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationE · patternCorrected Aug 6, 2024
- F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationE · patternCorrected Aug 6, 2024
- F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Resident RightsF · widespreadCorrected Aug 6, 2024
- F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Aug 6, 2024
- F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Infection ControlF · widespreadCorrected Aug 6, 2024
- Conduct mandatory training, for all staff, on the facilityâs Quality Assurance and Performance Improvement Program.AdministrationF · widespreadCorrected Aug 6, 2024
Apr 8, 2024Cycle 2worst E · no actual harm
- Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the residentâs advance directives.Quality of Life and CareE · patternCorrected May 7, 2024
Aug 9, 2023Cycle 2worst E · no actual harm
- F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceD · isolatedCorrected Sep 9, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Sep 9, 2023
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected Sep 9, 2023
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Sep 9, 2023
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Sep 9, 2023
- F761Ensure 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.Pharmacy ServiceE · patternCorrected Sep 9, 2023
Mar 8, 2023Cycle 3worst G · actual harm
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Mar 31, 2023
Apr 13, 2022Cycle 3worst F · no actual harm
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection ControlF · widespreadCorrected May 13, 2022
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 13, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined2.87hrs
- Registered nursesRN hours only0.61hrs
- Licensed practical nursesLPN hours0.53hrs
- Nurse aidesCNA hours1.72hrs
- Weekend nursingAll staff on Saturdays and Sundays2.63hrs
- Wisconsin average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better—WI avg 48%
- RN turnoverRegistered nurses only—Not ranked by CMS
- Administrators who leftIn the past year—
- Occupancy108 certified beds · ~82 residents a day76%Above 55% of peersWI avg 73%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $90,921In fines
- 2Fines
- 2Payment denials
- $41,875WI avg in fines
Actions on record
- Oct 7, 2024Civil money penalty$74,120
- Oct 7, 2024Denial of payment for new admissionsfrom Nov 6, 2024
- Jul 1, 2024Civil money penalty$16,801
- Jul 1, 2024Denial of payment for new admissionsfrom Jul 30, 2024
Ownership
As filed with CMSStructure
- Ownership type
- Non profit - Corporation
- Chain
- Ascension Living20 facilities in the chain2.6★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Ascension Health Senior Care
- Daniel Stricker
- Joan Bachleitner
- David Bordo
- Brad Foley
- Andrea Ohman
- Michael Gordon
- Daniel Stricker
- Michael Gordon
- Andrea Ohman
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 525523 · 9255 N 76TH ST, MILWAUKEE, WI, 53223.
- Percentiles compare this facility with every rated nursing home in Wisconsin and Milwaukee County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









