Cycle 1
Health 2025-05-21 · Fire 2025-05-21
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Milwaukee, WI
Mercy Health Services
3-star overall rating with 3-star inspections with $47,753 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2727 W Mitchell St, Milwaukee, WI
(414) 383-3699
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
60
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1988-10-08
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.83
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.77
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.29
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
3.32
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
79%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,119
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
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
0.52
Baseline 48.98% · Performance 61.54% · Measure score 0.52 · Achievement 0.52 · Improvement 0
Adjusted total nurse staffing
1.11
Baseline 3.81 hours · Performance 3.39 hours · Measure score 1.11 · Achievement 1.11 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.2% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 19.23% · Lower 95% interval 6.93% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 92% |
95.27%
3.3 pts worse
|
Numerator 23 · Denominator 25 |
| Falls with major injury | 8% |
0.77%
7.2 pts worse
|
Numerator 2 · Denominator 25 |
| 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% |
2.29%
1.7 pts worse
|
Numerator 1 · Denominator 25 · Adjusted rate 3.61% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.27% |
8.2%
5.9 pts worse
|
Numerator 1 · Denominator 44 |
| Staff flu vaccination coverage | 63.77% |
42%
21.8 pts better
|
Numerator 44 · Denominator 69 |
| 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 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · 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 | 74.2% |
95.7%
21.5 pts worse
|
93.4%
19.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 74.4% · Q2 77.1% · Q3 77.8% · Q4 66.7% · 4Q avg 74.2% |
| 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 · 4Q avg 100.0% |
| 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 5.1% · Q2 2.9% · Q3 3.7% · Q4 3.7% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.8% |
5.0%
0.2 pts better
|
11.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.0% · Q3 9.1% · Q4 4.3% · 4Q avg 4.8% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
4.9%
3.1 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 10.0% · Q3 8.0% · Q4 9.1% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.7% |
16.6%
9.9 pts better
|
19.6%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 6.1% · Q3 8.0% · Q4 12.0% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.9% |
16.7%
4.8 pts better
|
16.7%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 8.7% · 4Q avg 11.9% · 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 ability to walk independently worsened | 22.0% |
21.1%
0.9 pts worse
|
16.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.2% |
17.3%
2.9 pts worse
|
14.9%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 31.0% · Q3 18.2% · Q4 13.6% · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
2.3%
0.7 pts better
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
3.0%
1.3 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
25.5%
1.8 pts better
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 18.0% · Q3 20.1% · Q4 54.3% · 4Q avg 23.7% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
5.5%
1.6 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.5% · Q3 12.2% · Q4 10.8% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.8% |
86.8%
18 pts worse
|
81.7%
12.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 73.0% · Q2 75.0% · Q3 72.4% · Q4 59.6% · 4Q avg 68.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.5% |
15.0%
11.5 pts better
|
12.0%
8.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.5% · Observed 7.4% · Expected 23.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
1.3%
2.5 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 4.8% · Q4 4.3% · 4Q avg 3.8% · Used in QM five-star |
| 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 · 4Q avg 75.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.9% |
22.7%
6.2 pts worse
|
23.9%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.9% · Observed 55.6% · Expected 45.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2024-02-29
15 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-12-21 · Fire 2022-12-21
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-21
D · Potential for more than minimal harm
2025-05-21
K221 · Egress Deficiencies
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2025-06-21
D · Potential for more than minimal harm
2025-05-21
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-06-21
D · Potential for more than minimal harm
2025-05-21
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 2025-06-21
F · Potential for more than minimal harm
2024-02-29
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-02-29
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-03-25
F · Potential for more than minimal harm
2024-02-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-05
F · Potential for more than minimal harm
2024-02-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-29
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 2024-02-28
E · Potential for more than minimal harm
2024-02-29
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-08
F · Potential for more than minimal harm
2022-12-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-02-03
F · Potential for more than minimal harm
2022-12-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-03
F · Potential for more than minimal harm
2022-12-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-03
F · Potential for more than minimal harm
2022-12-21
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-02-03
F · Potential for more than minimal harm
2022-12-21
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-02-03
E · Potential for more than minimal harm
2022-12-21
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 2023-02-03
D · Potential for more than minimal harm
2022-12-21
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 2023-02-03
D · Potential for more than minimal harm
2022-12-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-03
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 2025-12-16
E · Potential for more than minimal harm
2025-05-21
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-21
D · Potential for more than minimal harm
2025-05-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-21
D · Potential for more than minimal harm
2025-05-21
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-06-21
E · Potential for more than minimal harm
2024-09-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-19
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 2024-10-18
D · Potential for more than minimal harm
2024-09-19
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 2024-10-18
D · Potential for more than minimal harm
2024-08-05
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 2024-09-04
D · Potential for more than minimal harm
2024-08-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-04
G · Actual harm
2024-05-13
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 2024-06-07
G · Actual harm
2024-02-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-29
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 2024-04-01
D · Potential for more than minimal harm
2024-02-29
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-29
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 2024-04-01
D · Potential for more than minimal harm
2024-02-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-29
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 2024-04-01
D · Potential for more than minimal harm
2024-02-29
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-01
F · Potential for more than minimal harm
2022-12-21
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 2023-01-26
F · Potential for more than minimal harm
2022-12-21
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 2023-01-26
F · Potential for more than minimal harm
2022-12-21
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 2023-01-26
E · Potential for more than minimal harm
2022-12-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-26
D · Potential for more than minimal harm
2022-12-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-01-26
D · Potential for more than minimal harm
2022-12-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-01-26
D · Potential for more than minimal harm
2022-12-21
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 2023-01-26
D · Potential for more than minimal harm
2022-12-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-26
D · Potential for more than minimal harm
2022-12-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-01-26
D · Potential for more than minimal harm
2022-12-21
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-01-26
D · Potential for more than minimal harm
2022-12-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-26
Penalties and ownership
What sits behind the stars
$14,050
2024-05-13
Fine
Fine · fine $14,050
Fine
$33,703
2024-02-29
Fine
Fine · fine $33,703
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
Hoehn, Jeffrey
Corporate Director · Individual
Hoehn, Jeffrey
W-2 Managing Employee · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
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