Menomonee Falls, WI

Menomonee Falls Health Services

1-star overall rating with 2-star inspections with $136,375 in total fines with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

N84 W17049 Menomonee Ave, Menomonee Falls, WI

(262) 255-1180

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

50

Certified beds

Average residents

32

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

North Shore Healthcare

Operator or chain grouping

Approved since

1988-08-11

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

0.67

Registered nurse staffing · state 0.97 · national 0.68

LPN hours / resident day

0.90

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

1.91

Nurse aide staffing · state 2.59 · national 2.35

Total nurse hours

3.49

All reported nurse hours · state 4.20 · national 3.89

Licensed hours

1.58

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.23

Weekend nurse staffing · state 3.72 · national 3.43

Weekend RN hours

0.56

Weekend registered nurse coverage · state 0.66 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.71

CMS adjusted RN staffing hours

Adjusted total hours

3.69

CMS adjusted total nurse staffing hours

Case-mix index

1.29

Higher values indicate more complex resident acuity

RN turnover

78%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

58%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,785

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

10.50

Composite VBP score used to determine payment impact.

Payment multiplier

0.9809

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

0

Baseline 67.31% · Performance 65.52% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

2.1

Baseline 3.09 hours · Performance 3.68 hours · Measure score 2.1 · Achievement 2.1 · Improvement 1.66

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 12.18%
10.72%
1.5 pts worse
No Different than the National Rate · Eligible stays 25 · Observed rate 28% · Lower 95% interval 8.17%
Discharge to community Not Available
50.57%
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary Not Available
1.02
Too few residents or stays to report publicly.
Drug regimen review with follow-up 52.38%
95.27%
42.9 pts worse
Numerator 11 · Denominator 21
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 21
Discharge self-care score Not Available
53.69%
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Discharge mobility score Not Available
50.94%
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened 4.76%
2.29%
2.5 pts worse
Numerator 1 · Denominator 21 · Adjusted rate 3.41%
Healthcare-associated infections requiring hospitalization Not Available
7.12%
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage 0%
8.2%
8.2 pts worse
Numerator 0 · Denominator 35
Staff flu vaccination coverage 69.81%
42%
27.8 pts better
Numerator 37 · Denominator 53
Discharge function score Not Available
56.45%
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date Not Available
25.2%
Numerator Not Available · Denominator 10 · 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 99.0%
95.7%
3.3 pts better
93.4%
5.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.7% · 4Q avg 99.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 83.9%
95.0%
11.1 pts worse
95.5%
11.6 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 83.9%
Percentage of long-stay residents experiencing one or more falls with major injury 3.9%
3.2%
0.7 pts worse
3.3%
0.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.7% · Q3 3.8% · Q4 4.3% · 4Q avg 3.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 14.9%
5.0%
9.9 pts worse
11.4%
3.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 19.0% · Q3 22.7% · Q4 13.6% · 4Q avg 14.9%
Percentage of long-stay residents who lose too much weight 7.1%
4.9%
2.2 pts worse
5.4%
1.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 8.7% · 4Q avg 7.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 9.0%
16.6%
7.6 pts better
19.6%
10.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 4.2% · Q3 14.3% · Q4 5.0% · 4Q avg 9.0%
Percentage of long-stay residents who received an antipsychotic medication 25.0%
16.7%
8.3 pts worse
16.7%
8.3 pts worse
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.0% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose need for help with daily activities has increased 32.9%
17.3%
15.6 pts worse
14.9%
18 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 41.7% · Q3 35.0% · 4Q avg 32.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 5.8%
2.3%
3.5 pts worse
1.0%
4.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 8.5% · Q3 8.8% · Q4 2.5% · 4Q avg 5.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 7.1%
3.0%
4.1 pts worse
1.7%
5.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 7.7% · Q3 8.3% · Q4 9.1% · 4Q avg 7.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 30.9%
25.5%
5.4 pts worse
19.8%
11.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 37.9% · Q2 25.6% · Q3 29.2% · Q4 29.5% · 4Q avg 30.9%
Percentage of long-stay residents with pressure ulcers 4.9%
5.5%
0.6 pts better
5.1%
0.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 0.0% · Q3 6.9% · Q4 4.0% · 4Q avg 4.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 69.3%
86.8%
17.5 pts worse
81.7%
12.4 pts worse
Short Stay · 2024Q4-2025Q3 · Q4 69.2% · 4Q avg 69.3%
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 · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-04 · Fire 2025-08-04

12 health deficiencies

Top issue: Infection Control (3 deficiencies)

7 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 2 Health 2024-05-01 · Fire 2024-05-01

31 health deficiencies

Top issue: Quality of Life and Care (11 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-03-23 · Fire 2023-03-23

5 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-08-04

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2025-08-25

D · Potential for more than minimal harm 2025-08-04

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 2025-08-22

D · Potential for more than minimal harm 2025-08-04

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 2025-08-22

D · Potential for more than minimal harm 2025-08-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-08-22

D · Potential for more than minimal harm 2025-08-04

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-08-04

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 2025-08-28

C · Minimal harm 2025-08-04

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-08-25

F · Potential for more than minimal harm 2024-05-01

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-06-06

F · Potential for more than minimal harm 2024-05-01

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-06-06

F · Potential for more than minimal harm 2024-05-01

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-06-09

E · Potential for more than minimal harm 2024-05-01

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2024-06-06

E · Potential for more than minimal harm 2024-05-01

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-01

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-06-07

D · Potential for more than minimal harm 2024-05-01

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 2024-06-06

D · Potential for more than minimal harm 2024-05-01

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-01

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-06-06

C · Minimal harm 2024-05-01

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-06-06

F · Potential for more than minimal harm 2023-03-23

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2023-04-28

F · Potential for more than minimal harm 2023-03-23

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-04-21

F · Potential for more than minimal harm 2023-03-23

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-04-28

E · Potential for more than minimal harm 2023-03-23

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-04-25

E · Potential for more than minimal harm 2023-03-23

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2023-04-28

E · Potential for more than minimal harm 2023-03-23

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2023-04-21

D · Potential for more than minimal harm 2023-03-23

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 2023-04-26

D · Potential for more than minimal harm 2023-03-23

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-04-21

D · Potential for more than minimal harm 2023-03-23

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-04-28

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-03

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2025-12-08

G · Actual harm 2025-08-04

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 2025-08-26

F · Potential for more than minimal harm 2025-08-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-03

F · Potential for more than minimal harm 2025-08-04

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2025-08-26

E · Potential for more than minimal harm 2025-08-04

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-08-26

E · Potential for more than minimal harm 2025-08-04

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-08-04

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-08-04

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-08-04

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 2025-08-26

D · Potential for more than minimal harm 2025-08-04

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-08-04

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-08-30

D · Potential for more than minimal harm 2025-08-04

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2025-08-30

G · Actual harm 2024-11-26

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-12-24

D · Potential for more than minimal harm 2024-11-26

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 2024-12-24

D · Potential for more than minimal harm 2024-11-26

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-12-24

D · Potential for more than minimal harm 2024-11-26

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2024-12-24

D · Potential for more than minimal harm 2024-11-26

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 2024-12-24

G · Actual harm 2024-05-01

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-06-06

G · Actual harm 2024-05-01

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 2024-06-06

F · Potential for more than minimal harm 2024-05-01

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 2024-06-06

F · Potential for more than minimal harm 2024-05-01

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 2024-06-06

F · Potential for more than minimal harm 2024-05-01

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-06-06

F · Potential for more than minimal harm 2024-05-01

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 2024-06-06

F · Potential for more than minimal harm 2024-05-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-06

E · Potential for more than minimal harm 2024-05-01

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-06-06

E · Potential for more than minimal harm 2024-05-01

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2024-06-06

E · Potential for more than minimal harm 2024-05-01

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-01

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-01

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-01

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 2024-06-06

D · Potential for more than minimal harm 2024-05-01

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 2024-06-06

D · Potential for more than minimal harm 2024-05-01

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-01

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-01

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-01

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 2024-06-06

D · Potential for more than minimal harm 2024-05-01

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-01

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-01

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-01

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-01

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 2024-06-06

D · Potential for more than minimal harm 2024-05-01

F811 · Nutrition and Dietary Deficiencies

Health

Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-01

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-01

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-06-06

G · Actual harm 2023-12-18

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-01-16

D · Potential for more than minimal harm 2023-12-18

F687 · Quality of Life and Care Deficiencies

Health

Provide appropriate foot care.

Corrected 2024-01-16

E · Potential for more than minimal harm 2023-03-23

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-04-21

D · Potential for more than minimal harm 2023-03-23

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 2023-04-21

D · Potential for more than minimal harm 2023-03-23

F888 · Infection Control Deficiencies

Health

Ensure staff are vaccinated for COVID-19

Corrected 2023-04-21

Penalties and ownership

What sits behind the stars

$47,850 2024-11-26

Fine

Fine · fine $47,850

Fine

$55,419 2024-05-01

Fine

Fine · fine $55,419

Fine

$0 2024-05-01

Payment Denial

Payment Denial · denial start 2024-06-01 · 8 days

8 day denial

$29,961 2023-12-18

Fine

Fine · fine $29,961

Fine

$3,145 2023-12-11

Fine

Fine · fine $3,145

Fine

Ownership

Nshf Operations LLC

5% Or Greater Direct Ownership Interest · Organization

100% 20 facilities 2017-07-24
Baumann, Troy

5% Or Greater Indirect Ownership Interest · Individual

40% 59 facilities 2017-06-29
Hoehn, Jeffrey

5% Or Greater Indirect Ownership Interest · Individual

40% 59 facilities 2017-06-29
Mills, David

5% Or Greater Indirect Ownership Interest · Individual

20% 40 facilities 2017-06-29
Baumann, Troy

Operational/Managerial Control · Individual

0% 59 facilities 2017-10-01
Baumann, Troy

Corporate Director · Individual

0% 59 facilities 2017-06-29
Belongia, Christina

Operational/Managerial Control · Individual

0% 16 facilities 2019-11-01
Cibc Bank Usa

Operational/Managerial Control · Organization

0% 121 facilities 2024-12-31
Cibc Bank Usa

5% Or Greater Security Interest · Organization

0% 121 facilities 2024-12-31
Cliftonlarsonallen Llp

Operational/Managerial Control · Organization

0% 23 facilities 2018-05-22
Continuum Therapy Partners

Operational/Managerial Control · Organization

0% 16 facilities 2025-03-01
Gee, Darren

Operational/Managerial Control · Individual

0% 16 facilities 2021-11-30
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Operational/Managerial Control · Individual

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Operational/Managerial Control · Individual

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Operational/Managerial Control · Individual

0% 59 facilities 2017-10-01
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Operational/Managerial Control · Organization

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Operational/Managerial Control · Organization

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Operational/Managerial Control · Individual

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Operational/Managerial Control · Individual

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Other facilities in reach

#1

Lindengrove Menomonee Falls

Menomonee Falls, WI

1-star overall rating with 1-star inspections with $142,393 in total fines with 37 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

Overall
1 / 5
Health
1 / 5
Staffing
3 / 5
Fines
$142,393
#2

Congregational Home, Inc

Brookfield, WI

4-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

Overall
4 / 5
Health
3 / 5
Staffing
5 / 5
Fines
$0
#3

Luther Manor

Milwaukee, WI

1-star overall rating with 1-star inspections with $170,666 in total fines with 18 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle

Overall
1 / 5
Health
1 / 5
Staffing
4 / 5
Fines
$170,666

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