Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Autumn Lake Healthcare at Greenfield
MILWAUKEE, WI · 112 certified beds · Last Life Safety survey December 12, 2024
CMS Certification Number 525504 · first certified January 1993
Ownership
Operated by AUTUMN LAKE HEALTHCARE · For profit - Limited Liability company
- Ownership changed February 22, 2018 (change of ownership)from CAMEO CARE CENTER INC.
Position within WI
19 citations — more than 54% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 7. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (January 2026 to March 2026), and past the point by which nine in ten WI facilities have been surveyed. This facility’s last Life Safety survey was December 2024. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 19 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
9 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 19 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 19 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 16, 2022 | 6 |
| September 11, 2023 | 8 |
| December 12, 2024 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2024-12-12 |
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2024-12-12 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2023-09-11 |
| K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | 2 | 2024-12-12 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2022-05-16 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2024-12-12 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2022-05-16 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2023-09-11 |
What the citations cover
- Smoke Deficiencies 5
- Miscellaneous Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Emergency Preparedness Deficiencies 3
- Other 5
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Miscellaneous Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Construction Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 12, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (January 8, 2025) |
| K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Deficient, Provider has date of correction (January 8, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 8, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (January 8, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 8, 2025) |
September 11, 2023 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Deficient, Provider has date of correction (October 13, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 5, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (October 26, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 27, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (September 14, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 22, 2023) |
May 16, 2022 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (June 25, 2022) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (June 25, 2022) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (June 1, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 4, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 1, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 30, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.