Starfile / Wisconsin

LUTHER MANOR

4545 N 92ND ST, MILWAUKEE, WI 53225 · CCN 525588

Inspection history vs Wisconsin & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$170,666

Number of fines

6

Number of penalties

8

Payment denials

2

Inspection citations (48)3 immediate jeopardy4 actual harm

1. GF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2026-01-14 · Health

   Actual harm

2. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-07-29 · Health · corrected 2025-08-21

   Potential for more than minimal harm

3. DF0585Honor 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.2025-05-13 · Health · corrected 2025-05-31

   Potential for more than minimal harm

4. DF0760Ensure that residents are free from significant medication errors.2025-03-26 · Health · corrected 2025-04-27

   Potential for more than minimal harm

5. DF0552Ensure that residents are fully informed and understand their health status, care and treatments.2024-10-31 · Health · corrected 2024-11-25

   Potential for more than minimal harm

6. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-10-31 · Health · corrected 2024-11-19

   Potential for more than minimal harm

7. DF0610Respond appropriately to all alleged violations.2024-10-31 · Health · corrected 2024-11-20

   Potential for more than minimal harm

8. DF0644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.2024-10-31 · Health · corrected 2024-11-25

   Potential for more than minimal harm

9. DF0645PASARR screening for Mental disorders or Intellectual Disabilities2024-10-31 · Health · corrected 2024-11-20

   Potential for more than minimal harm

10. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-10-31 · Health · corrected 2024-11-20

    Potential for more than minimal harm

11. DF0660Plan the resident's discharge to meet the resident's goals and needs.2024-10-31 · Health · corrected 2024-12-03

    Potential for more than minimal harm

12. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-10-31 · Health · corrected 2024-12-03

    Potential for more than minimal harm

13. DF0745Provide medically-related social services to help each resident achieve the highest possible quality of life.2024-10-31 · Health · corrected 2024-11-29

    Potential for more than minimal harm

14. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-09-10 · Health · corrected 2024-11-19

    Potential for more than minimal harm

15. DF0610Respond appropriately to all alleged violations.2024-09-10 · Health · corrected 2024-11-20

    Potential for more than minimal harm

16. DF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2024-09-10 · Health · corrected 2024-10-11

    Potential for more than minimal harm

17. DF0641Ensure each resident receives an accurate assessment.2024-09-10 · Health · corrected 2024-09-20

    Potential for more than minimal harm

18. EF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-09-10 · Health · corrected 2024-09-30

    Potential for more than minimal harm

19. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-09-10 · Health · corrected 2024-11-20

    Potential for more than minimal harm

20. JF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-09-10 · Health · corrected 2024-11-08

    Immediate jeopardy

21. JF0692Provide enough food/fluids to maintain a resident's health.2024-09-10 · Health · corrected 2024-09-20

    Immediate jeopardy

22. EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-09-10 · Health · corrected 2024-09-15

    Potential for more than minimal harm

23. DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2024-09-10 · Health · corrected 2024-09-19

    Potential for more than minimal harm

24. EF0758Implement 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.2024-09-10 · Health · corrected 2024-09-20

    Potential for more than minimal harm

25. DF0760Ensure that residents are free from significant medication errors.2024-09-10 · Health · corrected 2024-10-11

    Potential for more than minimal harm

26. FF0880Provide and implement an infection prevention and control program.2024-09-10 · Health · corrected 2024-11-08

    Potential for more than minimal harm

27. DF0947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.2024-09-10 · Health · corrected 2024-09-15

    Potential for more than minimal harm

28. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-06-11 · Health · corrected 2024-07-03

    Potential for more than minimal harm

29. DF0610Respond appropriately to all alleged violations.2024-06-11 · Health · corrected 2024-07-03

    Potential for more than minimal harm

30. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-06-11 · Health · corrected 2024-07-03

    Potential for more than minimal harm

31. JF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-06-11 · Health · corrected 2024-07-03

    Immediate jeopardy

32. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-06-11 · Health · corrected 2024-07-03

    Actual harm

33. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-02-01 · Health · corrected 2024-02-06

    Potential for more than minimal harm

34. DF0610Respond appropriately to all alleged violations.2024-02-01 · Health · corrected 2024-03-04

    Potential for more than minimal harm

35. GF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-02-01 · Health · corrected 2024-03-14

    Actual harm

36. GF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-02-01 · Health · corrected 2024-03-14

    Actual harm

37. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2024-02-01 · Health · corrected 2024-03-04

    Potential for more than minimal harm

38. EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-02-01 · Health · corrected 2024-03-04

    Potential for more than minimal harm

39. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-07-27 · Health · corrected 2023-08-25

    Potential for more than minimal harm

40. DF0610Respond appropriately to all alleged violations.2023-07-27 · Health · corrected 2023-08-25

    Potential for more than minimal harm

41. DF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2023-07-27 · Health · corrected 2023-08-23

    Potential for more than minimal harm

42. DF0625Notify 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.2023-07-27 · Health · corrected 2023-08-23

    Potential for more than minimal harm

43. DF0742Provide 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.2023-07-27 · Health · corrected 2023-08-25

    Potential for more than minimal harm

44. EF0758Implement 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.2023-07-27 · Health · corrected 2023-08-25

    Potential for more than minimal harm

45. DF0759Ensure medication error rates are not 5 percent or greater.2023-07-27 · Health · corrected 2023-08-25

    Potential for more than minimal harm

46. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-04-05 · Health · corrected 2023-05-05

    Potential for more than minimal harm

47. DF0692Provide enough food/fluids to maintain a resident's health.2022-04-04 · Health · corrected 2022-04-15

    Potential for more than minimal harm

48. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-04-04 · Health · corrected 2022-04-14

    Potential for more than minimal harm

Ownership

Other facilities in MILWAUKEE

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.