Cycle 1
Health 2025-12-03 · Fire 2025-12-03
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Monroe, WI
Monroe Health Services
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
516 26th Ave, Monroe, WI
(608) 325-9141
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
43
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1978-09-01
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
0.95
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,225
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.35
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
1.52
Baseline 19.83% · Performance 20.72% · Measure score 1.52 · Achievement 1.52 · Improvement 0
Healthcare-associated infections
0
Baseline 8.09% · Performance 9.32% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.42
Baseline 46.15% · Performance 57.89% · Measure score 1.42 · Achievement 1.42 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.28 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.68% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 4.17% · Lower 95% interval 6.06% |
| Discharge to community | 58.09% |
50.57%
7.5 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 54.35% · Lower 95% interval 46.95% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 59 · Denominator 59 |
| Falls with major injury | 1.69% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 59 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 18 · Denominator 42 |
| Discharge mobility score | 35.71% |
50.94%
15.2 pts worse
|
Numerator 15 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 5.08% |
2.29%
2.8 pts worse
|
Numerator 3 · Denominator 59 · Adjusted rate 4.9% |
| Healthcare-associated infections requiring hospitalization | 9.32% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 15.09% · Lower 95% interval 5.74% |
| Staff COVID-19 vaccination coverage | 2.08% |
8.2%
6.1 pts worse
|
Numerator 1 · Denominator 48 |
| Staff flu vaccination coverage | 43.33% |
42%
1.3 pts better
|
Numerator 26 · Denominator 60 |
| Discharge function score | 57.14% |
56.45%
0.7 pts better
|
Numerator 24 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 90% |
96.28%
6.3 pts worse
|
Numerator 18 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 10.34% |
25.2%
14.9 pts worse
|
Numerator 3 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.2
0.6 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
95.7%
0.6 pts worse
|
93.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 94.4% · Q3 90.6% · Q4 94.6% · 4Q avg 95.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
95.0%
2.6 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.2%
2.5 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
4.9%
1 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.5% · Q3 7.1% · Q4 2.9% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.8% |
16.6%
8.2 pts worse
|
19.6%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 21.2% · Q3 25.0% · Q4 26.5% · 4Q avg 24.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
16.7%
0.9 pts better
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 16.7% · Q3 18.2% · Q4 11.5% · 4Q avg 15.8% · 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 | 26.9% |
21.1%
5.8 pts worse
|
16.3%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
17.3%
0.3 pts worse
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 20.0% · Q3 23.1% · Q4 9.4% · 4Q avg 17.6% · 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 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
3.0%
0.6 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 0.0% · Q3 0.0% · Q4 8.1% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.4% |
25.5%
4.1 pts better
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 3.2% · Q3 26.6% · Q4 30.9% · 4Q avg 21.4% |
| 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 11.6% · Q2 10.5% · Q3 5.2% · Q4 9.4% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.7% |
86.8%
20.1 pts worse
|
81.7%
15 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 61.1% · Q2 62.5% · Q3 73.2% · Q4 72.2% · 4Q avg 66.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
15.0%
3.1 pts better
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 11.8% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.3%
1.7 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.3% · Q3 6.2% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.1% |
82.2%
25.1 pts worse
|
79.7%
22.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.5% |
22.7%
7.8 pts worse
|
23.9%
6.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.5% · Observed 29.4% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-08 · Fire 2024-08-08
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-04-25 · Fire 2023-04-25
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-03
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 2025-12-17
E · Potential for more than minimal harm
2025-12-03
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 2025-12-15
E · Potential for more than minimal harm
2025-12-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-12-15
E · Potential for more than minimal harm
2025-12-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-15
E · Potential for more than minimal harm
2025-12-03
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-12-15
F · Potential for more than minimal harm
2024-08-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-03
E · Potential for more than minimal harm
2024-08-08
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-10-03
E · Potential for more than minimal harm
2024-08-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-03
E · Potential for more than minimal harm
2024-08-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-03
E · Potential for more than minimal harm
2024-08-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-03
E · Potential for more than minimal harm
2023-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-04-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-04-25
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-04-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-04-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-03
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 2025-12-24
D · Potential for more than minimal harm
2025-12-03
F560 · Resident Rights Deficiencies
Health
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-12-03
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 2025-12-24
D · Potential for more than minimal harm
2025-12-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-01-17
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-02-04
D · Potential for more than minimal harm
2024-11-25
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 2024-12-11
D · Potential for more than minimal harm
2024-08-08
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 2024-09-06
D · Potential for more than minimal harm
2024-08-08
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 2024-09-06
D · Potential for more than minimal harm
2024-08-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-08
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-02-07
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 2024-03-01
D · Potential for more than minimal harm
2024-02-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-07
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 2024-03-01
D · Potential for more than minimal harm
2023-12-06
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-12-22
F · Potential for more than minimal harm
2023-04-25
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 2023-05-15
D · Potential for more than minimal harm
2023-04-25
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-04-25
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 2023-05-15
D · Potential for more than minimal harm
2023-04-25
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 2023-05-15
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
Baumann, Troy
Corporate Director · Individual
Baumann, Troy
W-2 Managing Employee · Individual
Hoehn, Jeffrey
Corporate Director · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
Nearby options
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#2
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1-star overall rating with 1-star inspections with abuse icon flag with $93,025 in total fines with 19 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
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4-star overall rating with 4-star inspections with $90,772 in total fines with 11 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
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