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
Staffing
Hours and turnover
RN hours / resident day
0.95
Registered nurse staffing
LPN hours / resident day
0.41
Licensed practical nurse staffing
Aide hours / resident day
2.22
Nurse aide staffing
Weekend hours
3.21
Weekend nurse staffing
RN turnover
46%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 3.9% |
4.9%
1 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 | 26.9% |
21.1%
5.8 pts worse
|
16.3%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
Other facilities in reach
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1-star overall rating with 1-star inspections with abuse icon flag with $67,298 in total fines with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
New Glarus Home
New Glarus, WI
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
Lena Living Center
Lena, IL
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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