Luther Manor
4545 N 92nd St, Milwaukee, WI 53225 · Milwaukee County · 99 certified beds · avg 95 residents/day · certified since May 1, 1996
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Sep 10, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 8, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Sep 10, 2024 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 20, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jun 11, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 3, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 14, 2026 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 16, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 11, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 3, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 1, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 14, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 1, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 14, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (50)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 14, 2026 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Dec 16, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Dec 16, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Dec 16, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Dec 16, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Dec 16, 2025 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| May 13, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Oct 31, 2024 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint |
| Oct 31, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 31, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Oct 31, 2024 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · from a complaint |
| Oct 31, 2024 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. · from a complaint |
| Oct 31, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Oct 31, 2024 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint |
| Oct 31, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Oct 31, 2024 | D · Potential for harm, one-off | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint |
| Sep 10, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Sep 10, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Sep 10, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 10, 2024 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Sep 10, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Sep 10, 2024 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Sep 10, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Sep 10, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Sep 10, 2024 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Sep 10, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Sep 10, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Sep 10, 2024 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Sep 10, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Sep 10, 2024 | D · Potential for harm, one-off | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Jun 11, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jun 11, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 11, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jun 11, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jun 11, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 1, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 1, 2024 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Feb 1, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Feb 1, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Feb 1, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Feb 1, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Jul 27, 2023 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jul 27, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jul 27, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Jul 27, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Jul 27, 2023 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Jul 27, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). |
| Jul 27, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (14 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 0 | E |
| 2024 | 34 | 6 | J ▲ |
| 2025 | 8 | 0 | E |
| 2026 | 1 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $163,627, plus 2 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Sep 10, 2024 | Fine | $103,705 |
| Sep 10, 2024 | Payment Denial | 53 days from Oct 11, 2024 |
| Jun 11, 2024 | Fine | $34,468 |
| Feb 1, 2024 | Fine | $25,454 |
| Feb 1, 2024 | Payment Denial | 14 days from Feb 29, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.60 | 4.29 | 3.95 | top 32% in Wisconsin; top 21% in the U.S. |
| Registered Nurse hours | 0.73 | 1.01 | 0.69 | bottom 26% in Wisconsin; top 33% in the U.S. |
| Weekend total nurse staffing | 4.13 | 3.84 | 3.50 | top 33% in Wisconsin; top 19% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.43 | 0.68 | 0.48 | bottom 22% in Wisconsin; top 42% in the U.S. |
| Total nursing staff turnover (%) | 55.2 | 46.9 | 45.8 | bottom 27% in Wisconsin; bottom 25% in the U.S. |
| RN turnover (%) | 68.2 | 39.7 | 42.9 | bottom 8% in Wisconsin; bottom 13% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.81, RN 0.77, weekend 4.32. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| United Lutheran Program for the Aging, INC | Organization | Direct Ownership Interest | NOT APPLICABLE | 01/01/1966 |
| Chedid, Stephanie | Individual | Corporate Officer | NOT APPLICABLE | 02/18/2015 |
| Chedid, Stephanie | Individual | ADP of the SNF | NOT APPLICABLE | 02/18/2015 |
| Cooper, Delila | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/15/2024 |
| Cooper, Delila | Individual | ADP of the SNF | NOT APPLICABLE | 04/15/2024 |
| Gibbs, Karen | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/27/2021 |
| Gibbs, Karen | Individual | ADP of the SNF | NOT APPLICABLE | 09/27/2021 |
| Hansen, Patrick | Individual | Corporate Officer | NOT APPLICABLE | 08/14/2017 |
| Hansen, Patrick | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/14/2017 |
| Hansen, Patrick | Individual | ADP of the SNF | NOT APPLICABLE | 08/14/2017 |
| Jung, Kim | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/09/2024 |
| Jung, Kim | Individual | ADP of the SNF | NOT APPLICABLE | 12/09/2024 |
| Keup, Arthur | Individual | Corporate Officer | NOT APPLICABLE | 11/13/2017 |
| Keup, Arthur | Individual | ADP of the SNF | NOT APPLICABLE | 11/13/2017 |
| Select Rehabilitation, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/24/2025 |
| Select Rehabilitation, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/24/2025 |
| Sodexo America, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/24/2025 |
| Sodexo America, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/24/2025 |
| United Lutheran Program for the Aging, INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/24/2025 |
| United Lutheran Program for the Aging, INC | Organization | ADP of the SNF | NOT APPLICABLE | 01/24/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "How do you coordinate and monitor care for residents who receive dialysis?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| St. Anne's Salvatorian Campus | 1.2 mi | Milwaukee, WI | ★☆☆☆☆ | 1/5 | |
| Lutheran Home | 3.1 mi | Wauwatosa, WI | ★★★★☆ | 3/5 | |
| Congregational Home, INC. | 3.4 mi | Brookfield, WI | ★★★★☆ | 3/5 | |
| St Camillus Health Center | 4.4 mi | Wauwatosa, WI | ★★☆☆☆ | 1/5 | |
| Bradley Estates Nursing and Rehab LLC | 4.6 mi | Milwaukee, WI | ★☆☆☆☆ | 1/5 | abuseSFF |
| Amethyst Health of Brown Deer | 4.9 mi | Milwaukee, WI | ★☆☆☆☆ | 1/5 | SFF |
| Complete Care at Glendale West | 5.3 mi | Glendale, WI | ★★★☆☆ | 2/5 | |
| Bayshore Nursing & Rehab | 5.3 mi | Glendale, WI | ★☆☆☆☆ | 1/5 | abuseSFF |
| Menomonee Falls Health Services | 5.4 mi | Menomonee Falls, WI | ★★☆☆☆ | 2/5 | |
| Lindengrove Menomonee Falls | 5.4 mi | Menomonee Falls, WI | ★☆☆☆☆ | 1/5 | |
| Milwaukee Health and Rehab | 5.5 mi | Milwaukee, WI | ★★★★☆ | 4/5 | |
| Resolve at West Allis Respiratory and Rehab | 5.9 mi | West Allis, WI | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 525588.