Cycle 1
Health 2025-08-19 · Fire 2025-08-19
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Lancaster, WI
Lancaster Health Services
2-star overall rating with 2-star inspections with $21,645 in total fines with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1350 S Madison St, Lancaster, WI
(608) 723-4143
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
39
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1984-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.70
Registered nurse staffing
LPN hours / resident day
0.79
Licensed practical nurse staffing
Aide hours / resident day
2.31
Nurse aide staffing
Weekend hours
3.33
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
37%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.7 |
2.2
1.5 pts worse
|
1.8
1.9 pts worse
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.7% |
95.0%
0.3 pts worse
|
95.5%
0.8 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.2%
2.4 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 11.1% |
5.0%
6.1 pts worse
|
11.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.5% |
4.9%
2.4 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.7% |
16.6%
1.1 pts worse
|
19.6%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 38.2% |
16.7%
21.5 pts worse
|
16.7%
21.5 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 ability to walk independently worsened | 30.3% |
21.1%
9.2 pts worse
|
16.3%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.4% |
17.3%
0.1 pts worse
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
2.3%
1.7 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
3.0%
2.3 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.8% |
25.5%
4.3 pts worse
|
19.8%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.5%
2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
86.8%
10.5 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.3%
1.3 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.9% |
82.2%
6.3 pts worse
|
79.7%
3.8 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-24 · Fire 2024-07-24
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-04-06 · Fire 2023-04-06
4 health deficiencies
Top issue: Infection Control (3 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-19
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-09-18
F · Potential for more than minimal harm
2025-08-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-09-18
F · Potential for more than minimal harm
2025-08-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-18
E · Potential for more than minimal harm
2025-08-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-09-18
E · Potential for more than minimal harm
2025-08-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-19
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-19
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-09-18
F · Potential for more than minimal harm
2024-07-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-24
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-24
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-24
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-08-23
E · Potential for more than minimal harm
2023-04-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-17
Inspection history
Recent health citations
J · Immediate jeopardy
2025-08-19
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-09-16
F · Potential for more than minimal harm
2025-08-19
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 2025-09-16
E · Potential for more than minimal harm
2025-08-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-08-19
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 2025-09-16
D · Potential for more than minimal harm
2025-08-19
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 2025-09-16
D · Potential for more than minimal harm
2025-08-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-08-19
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-02-19
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 2025-03-18
D · Potential for more than minimal harm
2025-02-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-18
D · Potential for more than minimal harm
2024-08-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-07-24
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 2024-03-05
D · Potential for more than minimal harm
2024-07-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-04-24
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 2024-05-03
F · Potential for more than minimal harm
2023-04-06
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 2023-05-02
F · Potential for more than minimal harm
2023-04-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-04-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-05-02
C · Minimal harm
2023-04-06
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-04-06
Penalties and ownership
What sits behind the stars
$21,645
2025-08-19
Fine
Fine · fine $21,645
Fine
Ownership
Nshr Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Arrowhead 123 LLC
5% Or Greater Indirect Ownership Interest · Organization
Baumann, Troy
5% Or Greater Indirect Ownership Interest · Individual
Baumann, Troy
Operational/Managerial Control · Individual
Baumann, Troy
Corporate Director · Individual
Hoehn, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Hoehn, Jeffrey
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Corporate Director · Individual
Mills, David
5% Or Greater Indirect Ownership Interest · Individual
Mills, David
Operational/Managerial Control · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
The Lane Morrell Bowen Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Orchard Manor
Lancaster, WI
5-star overall rating with 5-star inspections with $22,425 in total fines with 9 fire-safety deficiencies in the latest cycle
#2
Dove Healthcare - Fennimore
Fennimore, WI
1-star overall rating with 1-star inspections with abuse icon flag with $275,011 in total fines with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Edenbrook Of Platteville
Platteville, WI
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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