Facility WatchInspection records for every certified US nursing home
St. Anne's Salvatorian Campus
3800 N 92nd ST Milwaukee, WI 53222 (414) 463-7570
CCN
525524
Certified beds
50
Ownership
Non profit - Corporation
Chain
Illuminus
Nurse staffing
4.33
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 1.26 hours per resident per day
Nursing staff turnover: 50% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected January 7, 2026
2 citations · from a complaint investigation · Health
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected February 2, 2026
G
F0689Actual 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 March 2, 2026
Inspected June 13, 2025
3 citations · from a complaint investigation · Health
D
F0609No 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 11, 2025
D
F0755No actual harm with potential for more than minimal harm · Isolated
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 July 11, 2025
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected July 11, 2025
Inspected March 5, 2025
1 citation · from a complaint investigation · Health
G
F0760Actual harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected April 15, 2025
Inspected November 14, 2024
20 citations · from a complaint investigation · Health
D
F0554No actual harm with potential for more than minimal harm · Isolated
Allow residents to self-administer drugs if determined clinically appropriate.
Deficient, Provider has date of correction · corrected December 19, 2024
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected December 19, 2024
D
F0578No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Deficient, Provider has date of correction · corrected December 19, 2024
D
F0583No actual harm with potential for more than minimal harm · Isolated
Keep residents' personal and medical records private and confidential.
Deficient, Provider has date of correction · corrected December 19, 2024
D
F0645No 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 December 19, 2024
D
F0684No 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 April 15, 2025
D
F0690No 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 December 19, 2024
D
F0698No 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 December 19, 2024
D
F0700No actual harm with potential for more than minimal harm · Isolated
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Deficient, Provider has date of correction · corrected December 19, 2024
D
F0745No 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 December 19, 2024
D
F0759No 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 December 19, 2024
D
F0761No actual harm with potential for more than minimal harm · 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.
Deficient, Provider has date of correction · corrected December 19, 2024
D
F0849No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected December 19, 2024
D
F0881No actual harm with potential for more than minimal harm · Isolated
Implement a program that monitors antibiotic use.
Deficient, Provider has date of correction · corrected December 19, 2024
E
F0623No actual harm with potential for more than minimal harm · Pattern
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 December 19, 2024
E
F0725No actual harm with potential for more than minimal harm · Pattern
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Deficient, Provider has date of correction · corrected December 19, 2024
F
F0838No actual harm with potential for more than minimal harm · Widespread
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Deficient, Provider has date of correction · corrected December 19, 2024
F
F0880No 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 April 15, 2025
G
F0686Actual harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected April 15, 2025
G
F0689Actual 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 April 15, 2025
Inspected August 7, 2024
2 citations · from a complaint investigation · Health
D
F0609No 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 24, 2024
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected August 24, 2024
Inspected August 17, 2023
30 citations · from a complaint investigation · Health
B
F0623No actual harm with potential for minimal harm · Pattern
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 September 13, 2023
B
F0625No actual harm with potential for minimal harm · Pattern
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 September 13, 2023
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected September 13, 2023
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected September 13, 2023
D
F0687No actual harm with potential for more than minimal harm · Isolated
Provide appropriate foot care.
Deficient, Provider has date of correction · corrected September 13, 2023
D
F0690No 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 September 13, 2023
D
F0700No actual harm with potential for more than minimal harm · Isolated
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Deficient, Provider has date of correction · corrected September 13, 2023
D
F0745No 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 September 13, 2023
D
F0756No 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 13, 2023
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected September 13, 2023
D
F0758No actual harm with potential for more than minimal harm · Isolated
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 13, 2023
D
F0759No 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 September 13, 2023
D
F0773No actual harm with potential for more than minimal harm · Isolated
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Deficient, Provider has date of correction · corrected September 13, 2023
D
F0909No actual harm with potential for more than minimal harm · Isolated
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Deficient, Provider has date of correction · corrected September 13, 2023
E
F0655No actual harm with potential for more than minimal harm · Pattern
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Deficient, Provider has date of correction · corrected September 13, 2023
E
F0656No 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 13, 2023
E
F0677No actual harm with potential for more than minimal harm · Pattern
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected September 13, 2023
E
F0684No actual harm with potential for more than minimal harm · Pattern
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected September 13, 2023
E
F0689No actual harm with potential for more than minimal harm · Pattern
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 September 13, 2023
E
F0761No 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 September 13, 2023
E
F0941No actual harm with potential for more than minimal harm · Pattern
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Deficient, Provider has date of correction · corrected September 13, 2023
E
F0949No actual harm with potential for more than minimal harm · Pattern
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Deficient, Provider has date of correction · corrected September 13, 2023
F
F0584No actual harm with potential for more than minimal harm · Widespread
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Deficient, Provider has date of correction · corrected September 13, 2023
F
F0725No actual harm with potential for more than minimal harm · Widespread
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Deficient, Provider has date of correction · corrected September 13, 2023
F
F0727No actual harm with potential for more than minimal harm · Widespread
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Deficient, Provider has date of correction · corrected September 13, 2023
F
F0880No 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 September 13, 2023
F
F0882No actual harm with potential for more than minimal harm · Widespread
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Deficient, Provider has date of correction · corrected September 13, 2023
J
F0600Immediate jeopardy to resident health or safety · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected September 13, 2023
J
F0609Immediate jeopardy to resident health or safety · 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 September 13, 2023
J
F0686Immediate 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 September 13, 2023
Inspected June 8, 2022
3 citations · Health
D
F0585No 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 July 5, 2022
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected July 5, 2022
D
F0755No actual harm with potential for more than minimal harm · Isolated
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 July 5, 2022