Cycle 1
Health 2025-01-23 · Fire 2025-01-23
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cedarburg, WI
Cedarburg Health Services
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
N27 W5707 Lincoln Blvd, Cedarburg, WI
(262) 376-7676
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1995-07-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
58 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.38
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
4.72
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
79%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,358
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.68% · Performance 22.75% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.62% · Performance 8.70% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.55
Baseline 48.44% · Performance 40.98% · Measure score 5.55 · Achievement 5.55 · Improvement 2.66
Adjusted total nurse staffing
4
Baseline 4.68 hours · Performance 4.22 hours · Measure score 4 · Achievement 4 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.06% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 18.75% · Lower 95% interval 8.25% |
| Discharge to community | 47.36% |
50.57%
3.2 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 39.53% · Lower 95% interval 33.97% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 28.57% |
95.27%
66.7 pts worse
|
Numerator 10 · Denominator 35 |
| Falls with major injury | 2.86% |
0.77%
2.1 pts worse
|
Numerator 1 · Denominator 35 |
| Discharge self-care score | 59.09% |
53.69%
5.4 pts better
|
Numerator 13 · Denominator 22 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 12 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 5.71% |
2.29%
3.4 pts worse
|
Numerator 2 · Denominator 35 · Adjusted rate 6.29% |
| Healthcare-associated infections requiring hospitalization | 8.7% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 15.63% · Lower 95% interval 4.74% |
| Staff COVID-19 vaccination coverage | 4.23% |
8.2%
4 pts worse
|
Numerator 3 · Denominator 71 |
| Staff flu vaccination coverage | 33.82% |
42%
8.2 pts worse
|
Numerator 23 · Denominator 68 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 11 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.6% |
95.0%
0.6 pts better
|
95.5%
0.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
3.2%
2.5 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 4.7% · Q3 5.0% · Q4 5.3% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
5.0%
4.3 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
4.9%
About the same
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 9.7% · Q3 3.4% · Q4 0.0% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.7% |
16.6%
3.9 pts better
|
19.6%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 15.2% · Q3 12.9% · Q4 15.2% · 4Q avg 12.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.2% |
16.7%
7.5 pts worse
|
16.7%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 28.0% · Q3 23.8% · Q4 27.3% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 11.5% |
0.1%
11.4 pts worse
|
0.1%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 9.3% · Q3 10.0% · Q4 13.2% · 4Q avg 11.5% |
| Percentage of long-stay residents whose ability to walk independently worsened | 38.1% |
21.1%
17 pts worse
|
16.3%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.4% |
17.3%
4.1 pts worse
|
14.9%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 10.0% · Q3 19.2% · Q4 30.0% · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
2.3%
0.9 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 3.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.8% |
3.0%
4.8 pts worse
|
1.7%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 4.9% · Q3 7.9% · Q4 7.9% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.9% |
25.5%
8.4 pts worse
|
19.8%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 38.8% · Q3 29.9% · Q4 42.2% · 4Q avg 33.9% |
| Percentage of long-stay residents with pressure ulcers | 9.3% |
5.5%
3.8 pts worse
|
5.1%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 9.1% · Q3 9.5% · Q4 9.4% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.1% |
86.8%
1.7 pts worse
|
81.7%
3.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.6% · Q2 84.9% · Q3 82.7% · Q4 81.4% · 4Q avg 85.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.9% |
15.0%
5.1 pts better
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 9.4% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.3%
0.4 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 4.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.7% |
82.2%
19.5 pts worse
|
79.7%
17 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.0% |
22.7%
10.3 pts worse
|
23.9%
9.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.0% · Observed 31.2% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-29 · Fire 2023-11-29
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-08-24 · Fire 2022-08-24
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-23
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-02-17
F · Potential for more than minimal harm
2025-01-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-01-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-28
E · Potential for more than minimal harm
2025-01-23
K221 · Egress Deficiencies
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2025-01-24
E · Potential for more than minimal harm
2025-01-23
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-01-30
E · Potential for more than minimal harm
2025-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-05
E · Potential for more than minimal harm
2025-01-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-28
F · Potential for more than minimal harm
2023-11-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-29
E · Potential for more than minimal harm
2023-11-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-29
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-29
F · Potential for more than minimal harm
2022-08-24
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-10-08
E · Potential for more than minimal harm
2022-08-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-10-08
E · Potential for more than minimal harm
2022-08-24
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-24
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-10-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-01-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-01-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-01-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-01-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-19
D · Potential for more than minimal harm
2024-10-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-04
F585 · Resident Rights Deficiencies
Health
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 2024-10-25
E · Potential for more than minimal harm
2024-04-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-04-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-04-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-30
D · Potential for more than minimal harm
2023-11-29
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-29
F578 · Resident Rights Deficiencies
Health
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 2023-12-29
D · Potential for more than minimal harm
2023-11-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-11-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-05
F · Potential for more than minimal harm
2022-08-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-08
F · Potential for more than minimal harm
2022-08-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-24
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-24
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-10-08
Penalties and ownership
What sits behind the stars
Ownership
Nshf Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Baumann, Troy
5% Or Greater Indirect Ownership Interest · Individual
Hoehn, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Mills, David
5% Or Greater Indirect Ownership Interest · Individual
Hoehn, Jeffrey
W-2 Managing Employee · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
Nearby options
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5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Newcastle Place
Mequon, WI
3-star overall rating with 2-star inspections with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Complete Care at Germantown
Germantown, WI
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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