Facility Watch Inspection records for every certified US nursing home

Luther Manor

4545 N 92nd ST
Milwaukee, WI 53225
(414) 464-3880

CCN
525588
Certified beds
99
Ownership
Non profit - Corporation

Nurse staffing

4.74
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.69 hours per resident per day

Nursing staff turnover: 55% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected January 14, 2026

1 citation · from a complaint investigation · Health
G
F0686 Actual harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected February 16, 2026

Inspected December 16, 2025

5 citations · Health
D
F0585 No actual harm with potential for more than minimal harm · Isolated

Honor 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.

Deficient, Provider has date of correction · corrected January 17, 2026
D
F0605 No actual harm with potential for more than minimal harm · Isolated

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Deficient, Provider has date of correction · corrected January 17, 2026
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected January 17, 2026
D
F0698 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected January 17, 2026
E
F0761 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected January 17, 2026

Inspected July 29, 2025

1 citation · from a complaint investigation · Health
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected August 21, 2025

Inspected May 13, 2025

1 citation · from a complaint investigation · Health
D
F0585 No actual harm with potential for more than minimal harm · Isolated

Honor 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.

Deficient, Provider has date of correction · corrected May 31, 2025

Inspected March 26, 2025

1 citation · from a complaint investigation · Health
D
F0760 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected April 27, 2025

Inspected October 31, 2024

9 citations · from a complaint investigation · Health
D
F0552 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Deficient, Provider has date of correction · corrected November 25, 2024
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected November 19, 2024
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected November 20, 2024
D
F0644 No actual harm with potential for more than minimal harm · Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Deficient, Provider has date of correction · corrected November 25, 2024
D
F0645 No actual harm with potential for more than minimal harm · Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Deficient, Provider has date of correction · corrected November 20, 2024
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected November 20, 2024
D
F0660 No actual harm with potential for more than minimal harm · Isolated

Plan the resident's discharge to meet the resident's goals and needs.

Deficient, Provider has date of correction · corrected December 3, 2024
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected December 3, 2024
D
F0745 No actual harm with potential for more than minimal harm · Isolated

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Deficient, Provider has date of correction · corrected November 29, 2024

Inspected September 10, 2024

14 citations · from a complaint investigation · Health
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected November 19, 2024
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected November 20, 2024
D
F0623 No actual harm with potential for more than minimal harm · Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Deficient, Provider has date of correction · corrected October 11, 2024
D
F0641 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected September 20, 2024
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected November 20, 2024
D
F0756 No actual harm with potential for more than minimal harm · Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Deficient, Provider has date of correction · corrected September 19, 2024
D
F0760 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected October 11, 2024
D
F0947 No actual harm with potential for more than minimal harm · Isolated

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Deficient, Provider has date of correction · corrected September 15, 2024
E
F0656 No actual harm with potential for more than minimal harm · Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected September 30, 2024
E
F0755 No actual harm with potential for more than minimal harm · Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected September 15, 2024
E
F0758 No actual harm with potential for more than minimal harm · Pattern

Implement 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.

Deficient, Provider has date of correction · corrected September 20, 2024
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected November 8, 2024
J
F0686 Immediate jeopardy to resident health or safety · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected November 8, 2024
J
F0692 Immediate jeopardy to resident health or safety · Isolated

Provide enough food/fluids to maintain a resident's health.

Deficient, Provider has date of correction · corrected September 20, 2024

Inspected June 11, 2024

5 citations · from a complaint investigation · Health
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected July 3, 2024
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected July 3, 2024
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected July 3, 2024
G
F0689 Actual harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected July 3, 2024
J
F0686 Immediate jeopardy to resident health or safety · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected July 3, 2024

Inspected February 1, 2024

6 citations · from a complaint investigation · Health
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected February 6, 2024
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected March 4, 2024
D
F0690 No actual harm with potential for more than minimal harm · 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.

Deficient, Provider has date of correction · corrected March 4, 2024
E
F0755 No actual harm with potential for more than minimal harm · Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected March 4, 2024
G
F0684 Actual harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected March 14, 2024
G
F0686 Actual harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected March 14, 2024

Inspected July 27, 2023

7 citations · from a complaint investigation · Health
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected August 25, 2023
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected August 25, 2023
D
F0623 No actual harm with potential for more than minimal harm · Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Deficient, Provider has date of correction · corrected August 23, 2023
D
F0625 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected August 23, 2023
D
F0742 No actual harm with potential for more than minimal harm · Isolated

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Deficient, Provider has date of correction · corrected August 25, 2023
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected August 25, 2023
E
F0758 No actual harm with potential for more than minimal harm · Pattern

Implement 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.

Deficient, Provider has date of correction · corrected August 25, 2023

Penalties

DateTypeAmount
September 10, 2024Fine$103,705
September 10, 2024Payment Denial · 53 days
June 11, 2024Fine$34,468
February 1, 2024Fine$25,454
February 1, 2024Payment Denial · 14 days
August 14, 2023Fine$2,117
August 7, 2023Fine$1,748
July 17, 2023Fine$3,174