Autumn Lake Healthcare at Greenfield
5790 S 27th St · Milwaukee, WI · 53221 · 4142821300
112 certified beds For profit - Limited Liability company Chain: Autumn Lake Healthcare
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $152,619 in fines in the last 24 months.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
$152,619 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
72% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 4.19 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.77 | 0.55–0.75 |
| Weekend hours / resident-day | 3.80 | ≈ weekday level |
| Nursing turnover / year | 72% | median 45% |
| Fines (3-yr window) | 2 · $152,619 |
Inspection citations (65 in the current record)
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Immediate jeopardy · J December 13, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 14, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 13, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected December 14, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 13, 2025 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected January 15, 2026 · Quality of Life and Care
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Potential for harm · D December 13, 2025 · found via complaint
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected January 15, 2026 · Nutrition and Dietary
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Potential for harm · D December 13, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected December 15, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 8, 2025 · found via complaint
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.
Corrected July 29, 2025 · Resident Rights
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Potential for harm · D March 26, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected April 24, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 26, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected April 24, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 26, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 24, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 26, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected April 24, 2025 · Quality of Life and Care
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Potential for harm · D March 26, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 24, 2025 · Quality of Life and Care
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Potential for harm · D March 26, 2025 · found via complaint
Provide enough food/fluids to maintain a resident's health.
Corrected April 24, 2025 · Quality of Life and Care
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Potential for harm · D March 26, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected April 24, 2025 · Pharmacy Service
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Potential for harm · D March 26, 2025 · found via complaint
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected April 24, 2025 · Administration
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Potential for harm · D March 26, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected April 24, 2025 · Infection Control
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No harm found · C March 26, 2025 · found via complaint
Post nurse staffing information every day.
Corrected April 24, 2025 · Nursing and Physician Services
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Potential for harm · D December 12, 2024
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected January 19, 2025 · Resident Rights
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Potential for harm · E December 12, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected January 19, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 12, 2024
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected January 19, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 12, 2024
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected January 19, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 12, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected January 19, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 12, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected January 19, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 12, 2024
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected January 19, 2025 · Quality of Life and Care
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Potential for harm · D December 12, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 19, 2025 · Quality of Life and Care
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Potential for harm · D December 12, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected January 19, 2025 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 13, 2025 | Fine | $26,925 |
| August 13, 2024 | Fine | $125,694 |
| August 13, 2024 | Payment Denial | 54 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 525504 · certified since January 1, 1993. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.