Federal inspection record · CMS data as of October 1, 2026
Cedarburg Health Services
N27 W5707 Lincoln Blvd, Cedarburg, WI · (262) 376-7676
- Certified beds
- 50
- Residents per day
- 45
- Ownership
- For-Profit
- Chain
- North Shore Healthcare
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- July 27, 1995
1
How this home got 3 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Wisconsin.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★−1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Wisconsin homes
Cedarburg Health Services carries 27 inspection points. That is fewer than 74% of Wisconsin's 321 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Wisconsin: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–11 pts
- 4★ 11–37 pts
- 3★ 37–76 pts
- 2★ 76–130.75 pts
- 1★ over 130.75 pts
Bars show every rated home in Wisconsin by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
23 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Resident Rights6D
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
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.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
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.
Quality of Life and Care6E
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide enough food/fluids to maintain a resident's health.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Freedom from Abuse, Neglect, and Exploitation5D
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- D
Respond appropriately to all alleged violations.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Pharmacy Service4D
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure medication error rates are not 5 percent or greater.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Infection Control2D
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- D
Provide and implement an infection prevention and control program.
Inspection history
2026-04-29
4 health deficiencies · 2 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2025-01-23
8 health deficiencies · 7 fire-safety deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2023-11-29
11 health deficiencies · 4 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 27 min of nursing staff time a day, 53 min of it from a registered nurse.
This home
4 h 27 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 43% of nursing staff and 56% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days1.3 pts worse | 2.9 | 1.6 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.2 pts better | 2.0 | 2.2 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.3 pts worse | 95.7% | 96.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.3 pts better | 97.9% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.2 pts better | 3.1% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms5.3 pts better | 0.7% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.8 pts better | 4.1% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication4.5 pts better | 12.3% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication19.1 pts worse | 35.0% | 15.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained9.8 pts worse | 9.9% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened7.9 pts worse | 24.9% | 17.0% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased6.7 pts worse | 22.5% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.8 pts worse | 2.7% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection5.3 pts worse | 8.0% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence2.8 pts worse | 26.4% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.7 pts worse | 7.6% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine3.8 pts worse | 83.1% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit9.5 pts worse | 25.1% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medicationAbout the same | 1.2% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine2.2 pts worse | 80.0% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission16.2 pts worse | 38.7% | 22.5% | 23.4% |
·
Who owns and runs it
4 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Nshf Operations LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 20 facilities |
| Mills, David | 5% Or Greater Indirect Ownership Interest · Individual | 20% | 38 facilities |
| Hoehn, Jeffrey | W-2 Managing Employee · Individual | 0% | 57 facilities |
| North Shore Healthcare LLC | Operational/Managerial Control · Organization | 0% | 55 facilities |
·
Fire safety
13 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke4E
- E
Install a fire alarm system that can be heard throughout the facility.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Emergency Preparedness2F
- F
Establish policies and procedures including evacuation.
- F
Conduct testing and exercise requirements.
Miscellaneous2F
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Egress2E
- E
Provide rooms that can be unlocked from inside without a key.
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Gas, Vacuum, and Electrical Systems2F
- F
Ensure proper usage of power strips and extension cords.
- D
Have proper medical gas storage and administration areas.
Services1E
- E
Have properly installed electrical wiring and gas equipment.
·
Other homes nearby
-
Lasata Care Center
Cedarburg, WI
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 5 h 44 min
- Fines
- $0
-
Newcastle Place
Mequon, WI · Lifespace Communities
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 5 h 13 min
- Fines
- $8,281
-
Complete Care at Germantown
Germantown, WI · Complete Care
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 46 min
- Fines
- $0