Cycle 1
Health 2025-03-12 · Fire 2025-03-12
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Port Washington, WI
Heritage Health Services
2-star overall rating with 2-star inspections with $25,847 in total fines with 8 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
1119 N Wisconsin St, Port Washington, WI
(262) 284-5892
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
30
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1996-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.93
Registered nurse staffing
LPN hours / resident day
0.76
Licensed practical nurse staffing
Aide hours / resident day
1.86
Nurse aide staffing
Weekend hours
3.21
Weekend nurse staffing
RN turnover
86%
Annual RN turnover
Total nurse turnover
72%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
95.7%
2.3 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.2%
0.3 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.4% |
4.9%
1.5 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.7% |
16.6%
12.1 pts worse
|
19.6%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 22.2% |
16.7%
5.5 pts worse
|
16.7%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
17.3%
4 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.4% |
2.3%
2.1 pts worse
|
1.0%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.0%
3 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 41.1% |
25.5%
15.6 pts worse
|
19.8%
21.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 13.2% |
5.5%
7.7 pts worse
|
5.1%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.6% |
86.8%
15.2 pts worse
|
81.7%
10.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.3%
1.9 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.0% |
82.2%
12.2 pts worse
|
79.7%
9.7 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-06 · Fire 2024-02-06
19 health deficiencies
Top issue: Resident Rights (6 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Cycle 3
Health 2023-01-26 · Fire 2023-01-26
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-12
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-03-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-03-12
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-03-12
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 2025-04-11
E · Potential for more than minimal harm
2025-03-12
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-03-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-03-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-03-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-11
C · Minimal harm
2025-03-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-04-11
C · Minimal harm
2025-03-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-11
F · Potential for more than minimal harm
2024-02-06
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-03-04
F · Potential for more than minimal harm
2024-02-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-04
F · Potential for more than minimal harm
2024-02-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-04
F · Potential for more than minimal harm
2024-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-04
F · Potential for more than minimal harm
2024-02-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-04
F · Potential for more than minimal harm
2024-02-06
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-03-04
F · Potential for more than minimal harm
2024-02-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-04
E · Potential for more than minimal harm
2024-02-06
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-03-04
E · Potential for more than minimal harm
2024-02-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
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 2024-03-04
D · Potential for more than minimal harm
2024-02-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-04
C · Minimal harm
2024-02-06
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-03-04
C · Minimal harm
2024-02-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-04
F · Potential for more than minimal harm
2023-01-26
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-26
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-01-26
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 2023-03-10
E · Potential for more than minimal harm
2023-01-26
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-01-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-26
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-12
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 2025-04-11
F · Potential for more than minimal harm
2025-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-03-12
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-03-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-11
D · Potential for more than minimal harm
2024-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-02
L · Immediate jeopardy
2024-09-12
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-09-12
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 2024-10-08
D · Potential for more than minimal harm
2024-09-12
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-09-12
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 2024-10-08
C · Minimal harm
2024-09-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-10-08
F · Potential for more than minimal harm
2024-02-06
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-03-04
F · Potential for more than minimal harm
2024-02-06
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-03-04
F · Potential for more than minimal harm
2024-02-06
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 2024-03-04
F · Potential for more than minimal harm
2024-02-06
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-03-04
E · Potential for more than minimal harm
2024-02-06
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 2024-03-04
D · Potential for more than minimal harm
2024-02-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
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 2024-03-04
D · Potential for more than minimal harm
2024-02-06
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-04
C · Minimal harm
2024-02-06
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-03-04
C · Minimal harm
2024-02-06
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-03-04
D · Potential for more than minimal harm
2023-11-08
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 2023-12-07
D · Potential for more than minimal harm
2023-01-26
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 2023-03-10
D · Potential for more than minimal harm
2023-01-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-10
Penalties and ownership
What sits behind the stars
$25,847
2024-09-12
Fine
Fine · fine $25,847
Fine
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
Baumann, Troy
Corporate Director · Individual
Baumann, Troy
W-2 Managing Employee · Individual
Hoehn, Jeffrey
Corporate Director · Individual
Hoehn, Jeffrey
Corporate Officer · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
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