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Nursing HomeMedicaid Investigative

Autumn Lake Healthcare at Greenfield

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

5790 S 27th St, Copernicus Park · Milwaukee, WI 53221112 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.7/5

based on 96 Google reviews

5
4
3
2
1
Autumn Lake Healthcare at Greenfield Nursing Home in Milwaukee, WI — Street View
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7/ 10
critical Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Abuse citation on record
  • Low overall rating (1/5 stars)
  • Above-median deficiencies (28 vs median 7)
  • High staff turnover (73%)
  • High RN turnover (72%)

Bottom 25% in WI · Meets national RN staffing standard · Above recommended total nurse staffing · Very high staff turnover · Worst in AUTUMN LAKE HEALTHCARE chain · $176,440 in fines · Abuse citation

Source: Medicare data

What this means for your family

While the facility is physically modern and has a capable rehab team, the recurring reports of severe neglect, bed bugs, and medication errors are critical red flags. If you choose this facility, you must be prepared to be a highly active advocate, visit at varying times, and closely monitor your loved one's medical care and hygiene.

Google Reviews

Google Reviews

96 reviews on Google
Autumn Lake Healthcare at Greenfield receives highly polarized feedback, with many families reporting severe neglect, unsanitary conditions, and poor management, while others praise the facility for its physical appearance and specific staff members. Critical issues frequently cited include bed bug infestations, medication errors, and slow response times to call lights, particularly during night shifts. Families considering this facility should be aware of significant inconsistencies in care quality and reports of unprofessional administrative communication.

Quality Themes

Tap a score for details
Food2.0Staff4.0Clean3.0ActivitiesN/AMeds1.0MemoryN/AComms2.0ValueN/A

Strengths

  • Modern, clean, and well-maintained building
  • Effective physical and occupational therapy programs
  • Some highly dedicated and compassionate individual staff members
  • Spacious and comfortable private rooms

Concerns

  • Bed bug infestations in resident rooms (mentioned by 3 reviewers)
  • Medication errors and mismanagement (mentioned by 3 reviewers)
  • Neglect regarding hygiene, bathing, and basic care (mentioned by 5 reviewers)
  • Unresponsive or rude administrative leadership (mentioned by 6 reviewers)
  • Slow or non-existent response to call lights (mentioned by 4 reviewers)
  • Understaffing and reliance on agency workers (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

234'16(1)'18(2)'20(4)'22(4)'24(17)'26(7)

Distribution · 101 analyzed

5
62
4
6
3
0
2
2
1
31
21 reviews posted between Jun 8, 2023Jun 10, 2023 · 21 were 5-star

How They Respond to Reviews

97%response rate

This facility actively engages with reviewer feedback.

Questions for Your Tour

  • 1Given the recent focus on facility maintenance, what specific protocols are currently in place to ensure ongoing room hygiene and pest prevention?
  • 2I noticed that medication management is a high priority for our family; could you walk us through the safeguards and double-check systems you have in place to prevent errors?
  • 3How does your nursing team prioritize and respond to call lights, and what is the expected turnaround time for a resident needing assistance?
  • 4I appreciate that the leadership team is active in responding to feedback online; how do you incorporate that family input into your day-to-day operations and staff training?
  • 5With the therapy programs being a noted strength here, how do you integrate those sessions into a resident's daily routine to ensure they stay active and engaged?
  • 6Could you describe the process for how staff monitors and assists residents with daily hygiene and bathing to ensure consistent, high-quality care?

Personalized based on this facility's data


Key Review Excerpts

My sister was in this facility for less than a week and I had to call 911 to have her taken to the ER. She had a blood infection from a neglected PICC line and unsanitary practices by staff.

Long-term resident's family · 2025☆☆☆☆

The night staff was absolutely terrible. I had to help my mom call the main line in several occasions because the call light was on and no one would come. One night worker told her “my back hurts, I ain’t coming back in here no more.”

Long-term resident's family · 2025☆☆☆☆

Their physical and occupational therapists, with their expertise and kind inspiring words, gave my mom the motivation she needed to recover. The nurses and CNAs were so compassionate.

Rehab patient's family · 2026★★★★★
Source: 96 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.77hrs
OK
Registered nurses for medical care
Total Nursing
4.19hrs
OK
All nurses + aides combined
Staff Turnover
72%
Lower is better (< 30% = good)
RN Turnover
67%
Lower is better (< 30% = good)

This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

14

measures

Worse Than Avg

3

measures

Long-Stay Residents
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility5.5%
Better than Avg
Here
5.5%
US
14.4%
WI
16.7%
Milwaukee
15.7%
😔

Residents with depression symptoms

↓ Lower is better
This Facility1.3%
Better than Avg
Here
1.3%
US
12.1%
WI
5.2%
Milwaukee
4.2%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
WI
95.6%
Milwaukee
90.0%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility29.2%
Worse than Avg
Here
29.2%
US
19.4%
WI
25.0%
Milwaukee
26.9%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility13.5%
Better than Avg
Here
13.5%
US
15.3%
WI
19.9%
Milwaukee
22.4%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility16.4%
Worse than Avg
Here
16.4%
US
15.4%
WI
15.9%
Milwaukee
10.5%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility99.8%
Better than Avg
Here
99.8%
US
81.8%
WI
86.6%
Milwaukee
76.4%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility95.7%
Better than Avg
Here
95.7%
US
79.7%
WI
82.2%
Milwaukee
72.5%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.8%
Better than Avg
Here
0.8%
US
1.6%
WI
1.3%
Milwaukee
1.0%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

18deficiencies
3penalties
Well above state avg (9.8)
45 complaint-triggered
$176,440 in fines

Families have filed complaints that triggered nearly half of the 95 deficiencies found across 12 surveys, with recurring issues in pressure ulcer prevention, resident safety, and medication management. The facility has struggled with serious problems including an abuse case requiring immediate protection, medication errors exceeding acceptable rates, and repeated failures in wound care and accident prevention that persist across multiple years of inspections, though all violations show correction dates.

Dec 13, 2025Complaint
5
0600Immediate jeopardy · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0806Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Jul 8, 2025Complaint
1
0585Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

Mar 26, 2025Complaint
10
0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0773Potential for harm · IsolatedCorrected

Administration Deficiencies

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0732Minimal · WidespreadCorrected

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Dec 12, 2024Routine
16
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0031Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Provide emergency officials' contact information.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0607Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

0132Potential for harm · PatternCorrected

Construction Deficiencies

Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0638Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Assure that each resident’s assessment is updated at least once every 3 months.

0640Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

0645Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0345Minimal · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0712Minimal · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Dec 12, 2024Complaint
1
0697Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Sep 25, 2024Complaint
3
0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Federal Penalties

Fine

Dec 13, 2025

$26,925

Fine

Aug 13, 2024

$125,694

Payment Denial

Aug 13, 2024

54-day denial

Ownership & Operations

Who Operates This Facility

Owner / Operator

Autumn Lake Healthcare at Greenfield

Organization Type

for profit

Chain Affiliation

Chain Name

Autumn Lake Healthcare

Chain Size

60 facilities nationwide

Chain avg rating: 2.8/5 · Rank 56 of 60 (Worst)

Ownership & Management

Owners

AL Three LLC

Owner · Organization

25%

Davis, Yehoshua

Owner

15%

Wisconsin Acquisitions LLC

Owner · Organization

Markstein, Isaac

Owner

Klein, Joseph

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Lichtenstein, Simcha

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Lowy, Joel

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Markstein, Aaron

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Markstein, Avrohom

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Markstein, Mayer

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Pines, Esther

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Silber, Naftali

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Key personnel

Cameo Realty LLC5% or Greater Mortgage InterestSchwartz, MarkOfficer / DirectorBohman, AnnetteManagerRamnanan, KeshniManagerSchwartz, MarkManager
Source: Medicare provider data

Contact

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References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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