F58

LUTHER MANOR

Grade F 58/100 composite score

Non profit - Corporation

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
2/5
Staffing
4/5
RN Staffing
Not rated

Certified Beds

99

Ownership

Non profit - Corporation

Total Fines

$170,666

Last Survey

N/A

4545 N 92ND ST, MILWAUKEE, WI 53225
4144643880

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.66h
LPN
1.18h
CNA
2.78h
Total
4.63h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

UNITED LUTHERAN PROGRAM FOR THE AGING, INC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jan 1966

SELECT REHABILITATION, LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jan 2025

SODEXO AMERICA, LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jan 2025

UNITED LUTHERAN PROGRAM FOR THE AGING, INC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jan 2025

COOPER, DELILA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2024

GIBBS, KAREN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2021

HANSEN, PATRICK

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Aug 2017

JUNG, KIM

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Dec 2024

CHEDID, STEPHANIE

IndividualCORPORATE OFFICERSince Feb 2015

HANSEN, PATRICK

IndividualCORPORATE OFFICERSince Aug 2017

KEUP, ARTHUR

IndividualCORPORATE OFFICERSince Nov 2017

Penalties & Fines (8)

$170,666total fines
DateTypeDescriptionAmount
Sep 10, 2024Fine$103,705
Sep 10, 2024Payment Denial
Jun 11, 2024Fine$34,468
Feb 1, 2024Fine$25,454
Feb 1, 2024Payment Denial
Aug 14, 2023Fine$2,117
Aug 7, 2023Fine$1,748
Jul 17, 2023Fine$3,174

Health Inspection Deficiencies (47)

July 29, 2025Health1 deficiency
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 21, 2025
May 13, 2025Health1 deficiency
0585DMinimal 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.

Resident Rights Deficiencies

Corrected May 31, 2025
March 26, 2025Health1 deficiency
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Apr 27, 2025
October 31, 2024Health9 deficiencies
0552DMinimal harm, Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Corrected Nov 25, 2024
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 19, 2024
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 20, 2024
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 25, 2024
0645DMinimal harm, Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Corrected Nov 20, 2024
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 20, 2024
0660DMinimal harm, Isolated

Plan the resident's discharge to meet the resident's goals and needs.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 3, 2024
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Dec 3, 2024
0745DMinimal harm, Isolated

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Quality of Life and Care Deficiencies

Corrected Nov 29, 2024
September 10, 2024Health14 deficiencies2 severe
0623DMinimal harm, Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Oct 11, 2024
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Sep 20, 2024
0656EMinimal harm, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Sep 30, 2024
0692JImmediate jeopardy, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Sep 20, 2024
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Sep 15, 2024
0756DMinimal 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.

Pharmacy Service Deficiencies

Corrected Sep 19, 2024
0758EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Sep 20, 2024
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Oct 11, 2024
0880FMinimal harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Nov 8, 2024
0947DMinimal harm, Isolated

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Nursing and Physician Services Deficiencies

Corrected Sep 15, 2024
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 19, 2024
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 20, 2024
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 20, 2024
0686JImmediate jeopardy, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Nov 8, 2024
June 11, 2024Health5 deficiencies2 severe
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 3, 2024
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 3, 2024
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Jul 3, 2024
0686JImmediate jeopardy, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Jul 3, 2024
0689GActual harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Jul 3, 2024
February 1, 2024Health6 deficiencies2 severe
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Feb 6, 2024
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 4, 2024
0684GActual harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Mar 14, 2024
0686GActual harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Mar 14, 2024
0690DMinimal 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.

Quality of Life and Care Deficiencies

Corrected Mar 4, 2024
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Mar 4, 2024
July 27, 2023Health7 deficiencies
0623DMinimal harm, Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Aug 23, 2023
0625DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Aug 23, 2023
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Aug 25, 2023
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 25, 2023
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 25, 2023
0742DMinimal harm, Isolated

Provide 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.

Quality of Life and Care Deficiencies

Corrected Aug 25, 2023
0758EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Aug 25, 2023
April 5, 2023Health1 deficiency
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected May 5, 2023
April 4, 2022Health2 deficiencies
0692DMinimal harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Apr 15, 2022
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Apr 14, 2022

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Frequently Asked Questions

What is the CareGrader rating for LUTHER MANOR?

LUTHER MANOR in MILWAUKEE, Wisconsin has a CareGrader grade of F (Poor), with a composite score of 58.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for LUTHER MANOR?

LUTHER MANOR has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 4/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does LUTHER MANOR have?

LUTHER MANOR has 47 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has LUTHER MANOR been fined?

Yes. LUTHER MANOR has $170,666 in total fines from CMS enforcement actions across 8 penalties.

How many beds does LUTHER MANOR have?

LUTHER MANOR has 99 certified beds with approximately 94 current residents (95% occupancy). The facility is located at 4545 N 92ND ST, MILWAUKEE, Wisconsin 53225. It is a non profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.