01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-16 | 6 | 2025-12-16 | 11 |
| Cycle 2 | 2024-09-10 | 26 | 2024-09-10 | 11 |
| Cycle 3 | 2023-07-27 | 18 | 2023-07-27 | 11 |
CMS CCN 5255882026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Luther Manor
4545 N 92Nd St · Milwaukee, WI 53225 · Milwaukee County
Certified beds99CMS provider file
Recent citation rows83current CMS citation release
Penalty rows5current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
83 rows in the current release
7 rows carry G–L scope/severity codes; 3 carry J–L. 18 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-01-14 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-02-16 · complaint2025-12-16 · HEALTHF0585Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-01-172025-12-16 · HEALTHF0605Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Correction field: Deficient, Provider has date of correction · 2026-01-172025-12-16 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-01-172025-12-16 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2026-01-172025-12-16 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-01-172025-12-16 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-01-172025-12-16 · FIREK0311Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Have an enclosure around a vertical opening shaft.
Correction field: Deficient, Provider has date of correction · 2026-01-172025-12-16 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2026-01-172025-12-16 · FIREK0351Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2026-01-172025-12-16 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-02-282025-12-16 · FIREK0374Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has plan of correction2025-12-16 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2026-01-172025-12-16 · FIREK0741Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2026-01-302025-12-16 · FIREK0753Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of highly flammable decorations.
Correction field: Deficient, Provider has date of correction · 2026-01-172025-12-16 · FIREK0781Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of portable space heaters.
Correction field: Deficient, Provider has date of correction · 2026-01-172025-12-16 · FIREK0923Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2026-01-172025-07-29 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-08-21 · complaint2025-05-13 · HEALTHF0585Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-05-31 · complaint2025-03-26 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-04-27 · complaint2024-10-31 · HEALTHF0552Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2024-11-25 · complaint2024-10-31 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-11-19 · complaint2024-10-31 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-11-20 · complaint2024-10-31 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2024-11-25 · complaint03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-09-10 | Fine | $103,705 | 0 |
| 2024-09-10 | Payment Denial | $0 | 53 |
| 2024-06-11 | Fine | $34,468 | 0 |
| 2024-02-01 | Fine | $25,454 | 0 |
| 2024-02-01 | Payment Denial | $0 | 14 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- UNITED LUTHERAN PROGRAM FOR THE AGING, INCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 01/01/1966
- CHEDID, STEPHANIEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/18/2015
- HANSEN, PATRICKIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/14/2017
- KEUP, ARTHURIndividual · CORPORATE OFFICERNOT APPLICABLE · since 11/13/2017
- SELECT REHABILITATION, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/24/2025
- SODEXO AMERICA, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/24/2025
- UNITED LUTHERAN PROGRAM FOR THE AGING, INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/24/2025
- COOPER, DELILAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/15/2024
- GIBBS, KARENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/27/2021
- HANSEN, PATRICKIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/14/2017
- JUNG, KIMIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/09/2024
- SELECT REHABILITATION, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 01/24/2025
- SODEXO AMERICA, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 01/24/2025
- UNITED LUTHERAN PROGRAM FOR THE AGING, INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 01/24/2025
- CHEDID, STEPHANIEIndividual · ADP OF THE SNFNOT APPLICABLE · since 02/18/2015
- COOPER, DELILAIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/15/2024
- GIBBS, KARENIndividual · ADP OF THE SNFNOT APPLICABLE · since 09/27/2021
- HANSEN, PATRICKIndividual · ADP OF THE SNFNOT APPLICABLE · since 08/14/2017
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.81per resident day
RN hours0.77per resident day
Weekend nurse hours4.32per resident day
Staff turnover55.2%CMS reported field
06 / LOCAL RECORDS
Open the Milwaukee ledger →Other published facilities nearby
Amethyst Health Of Brown Deer87 beds · CMS overall 1/5116 citation rowsAutumn Lake Healthcare At Greenfield112 beds · CMS overall 1/595 citation rowsAvina Of Milwaukee108 beds · CMS overall 1/5119 citation rowsBradley Estates Nursing And Rehab Llc198 beds · CMS overall 1/5189 citation rowsEastcastle Pl Bradford Ter Conv Ctr40 beds · CMS overall 5/522 citation rowsEdenbrook Lakeside145 beds · CMS overall 1/564 citation rowsJewish Home And Care Center102 beds · CMS overall 1/549 citation rowsMaple Ridge Health Services80 beds · CMS overall 2/546 citation rows