01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-06-10 | 10 | 2025-06-10 | 4 |
| Cycle 2 | 2024-03-14 | 8 | 2024-03-14 | 5 |
| Cycle 3 | 2022-12-13 | 2 | 2022-12-13 | 2 |
CMS CCN 5255452026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Lutheran Home
7500 W North Ave · Wauwatosa, WI 53213 · Milwaukee County
Certified beds160CMS provider file
Recent citation rows31current CMS citation release
Penalty rows0current 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
31 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 7 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-06-10 · HEALTHF0628Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2025-07-102025-06-10 · HEALTHF0641Severity B · pattern; potential for minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-07-102025-06-10 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-07-10 · complaint2025-06-10 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-07-102025-06-10 · HEALTHF0686Severity D · isolated; potential for more than minimal 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 · 2025-07-102025-06-10 · HEALTHF0697Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-07-10 · complaint2025-06-10 · HEALTHF0761Severity D · isolated; 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 · 2025-07-102025-06-10 · HEALTHF0804Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2025-07-102025-06-10 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-07-102025-06-10 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-07-102025-06-10 · FIREK0233Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Install resident room doors of proper design and width.
Correction field: Deficient, Provider has date of correction · 2025-07-102025-06-10 · FIREK0293Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2025-07-102025-06-10 · FIREK0321Severity E · pattern; 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 · 2025-07-102025-06-10 · 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 · 2025-07-102025-02-04 · 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 · 2025-03-04 · complaint2024-03-14 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2024-04-142024-03-14 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-04-142024-03-14 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2024-04-142024-03-14 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2024-04-142024-03-14 · HEALTHF0761Severity D · isolated; 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 · 2024-04-142024-03-14 · HEALTHF0804Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2024-04-142024-03-14 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-04-142024-03-14 · 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 · 2024-03-272024-03-14 · 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 · 2024-03-2703 / 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 |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- DENOR, JIMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2021
- EHN, DIANEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/01/2021
- HODAN, MIKEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2023
- KEBBEKUS, BENIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2021
- KRIETE, LINDSEYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2023
- MUELLER, GARYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2021
- PEDERSEN, HARRIETIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2018
- RAASCH, RANDYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2023
- REARDON, TIMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/01/2019
- ROSENBERG, PAULIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/01/2021
- SANDSTROM, DAVIDIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/01/2021
- SURMA, KRISTINAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/01/2021
- TRISKA WIEMER, KATIEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2023
- DENOR, JIMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2021
- EHN, DIANEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/2021
- HODAN, MIKEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2023
- KEBBEKUS, BENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2021
- KRIETE, LINDSEYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2023
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 hours4.28per resident day
RN hours0.99per resident day
Weekend nurse hours3.80per resident day
Staff turnover37.4%CMS reported field
06 / LOCAL RECORDS
Open the Wauwatosa ledger →