Cycle 1
Health 2025-04-10 · Fire 2025-04-10
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Saint Francis, WI
St Francis Health Services
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1915 E Tripoli Ave, Saint Francis, WI
(414) 483-3611
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
34
Certified beds
Average residents
33
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1991-11-01
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
0.46
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.10
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.92
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.46
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
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
33%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,938
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
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
1.97
Baseline 68.75% · Performance 57.89% · Measure score 1.97 · Achievement 1.42 · Improvement 1.97
Adjusted total nurse staffing
1.74
Baseline 3.67 hours · Performance 3.57 hours · Measure score 1.74 · Achievement 1.74 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 7.14% · Lower 95% interval 6.68% |
| Discharge to community | 49.78% |
50.57%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 45% · Lower 95% interval 34.08% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 86.11% |
95.27%
9.2 pts worse
|
Numerator 31 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 60% |
53.69%
6.3 pts better
|
Numerator 18 · Denominator 30 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 15 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 36 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 21.21% |
8.2%
13 pts better
|
Numerator 7 · Denominator 33 |
| Staff flu vaccination coverage | 62.22% |
42%
20.2 pts better
|
Numerator 28 · Denominator 45 |
| Discharge function score | 63.33% |
56.45%
6.9 pts better
|
Numerator 19 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 90.91% |
96.28%
5.4 pts worse
|
Numerator 20 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 29.63% |
25.2%
4.4 pts better
|
Numerator 8 · Denominator 27 |
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 96.2% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.6% |
95.0%
2.4 pts worse
|
95.5%
2.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.2%
0.8 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 8.0% · Q4 7.7% · 4Q avg 4.0% · 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 | 0.0% |
4.9%
4.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.9% |
16.6%
1.7 pts better
|
19.6%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 19.0% · Q3 14.3% · Q4 14.3% · 4Q avg 14.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
16.7%
8.2 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.5% · 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 | 30.7% |
21.1%
9.6 pts worse
|
16.3%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.7% · Used in QM five-star |
| 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 27.3% · Q2 35.0% · Q3 40.0% · Q4 30.0% · 4Q avg 32.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
2.3%
1 pts better
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
3.0%
0.1 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.2% |
25.5%
10.7 pts worse
|
19.8%
16.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 57.7% · Q3 27.0% · Q4 36.3% · 4Q avg 36.2% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
5.5%
3.8 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 0.0% · Q4 3.4% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.4% |
86.8%
10.4 pts worse
|
81.7%
5.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 86.0% · Q3 83.7% · Q4 55.8% · 4Q avg 76.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.0% |
15.0%
About the same
|
12.0%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 14.3% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.1% |
82.2%
23.1 pts worse
|
79.7%
20.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.7% |
22.7%
8 pts better
|
23.9%
9.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.7% · Observed 14.3% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-01 · Fire 2024-02-01
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-11-23 · Fire 2022-11-23
0 health deficiencies
No concentrated health issue counts in this cycle.
4 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
2025-04-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-10
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-10
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Not marked corrected
D · Potential for more than minimal harm
2025-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-10
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-05-09
F · Potential for more than minimal harm
2024-02-01
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-02-23
F · Potential for more than minimal harm
2024-02-01
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-02-23
F · Potential for more than minimal harm
2024-02-01
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-02-20
F · Potential for more than minimal harm
2024-02-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-21
E · Potential for more than minimal harm
2024-02-01
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-02-01
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-02-01
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-02-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-26
F · Potential for more than minimal harm
2022-11-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-09
F · Potential for more than minimal harm
2022-11-23
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-11-23
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-10
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 2025-05-09
D · Potential for more than minimal harm
2025-04-10
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 2025-05-09
D · Potential for more than minimal harm
2025-04-10
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 2025-05-09
D · Potential for more than minimal harm
2025-04-10
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 2025-05-09
F · Potential for more than minimal harm
2024-02-01
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 2024-02-29
Penalties and ownership
What sits behind the stars
Ownership
Nshc Wisconsin LLC
5% Or Greater Direct Ownership Interest · Organization
Baumann, Troy
Operational/Managerial Control · Individual
Baumann, Troy
Corporate Officer · Individual
Belongia, Christina
Operational/Managerial Control · Individual
Cibc Bank Usa
Operational/Managerial Control · Organization
Cibc Bank Usa
5% Or Greater Security Interest · Organization
Cibc Bank Usa
5% Or Greater Mortgage Interest · Organization
Cliftonlarsonallen Llp
Operational/Managerial Control · Organization
Continuum Therapy Partners
Operational/Managerial Control · Organization
Gee, Darren
Operational/Managerial Control · Individual
Greer, Lauren
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Corporate Officer · Individual
Lopez, Ann
Operational/Managerial Control · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
Nsh Rehab LLC
Operational/Managerial Control · Organization
Patzer, Colleen
Operational/Managerial Control · Individual
Purtell, Brian
Operational/Managerial Control · Individual
Sidhu, Sarfraz
Operational/Managerial Control · Individual
Wipfli Llp
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Wheaton Franciscan Hc - Terrace At St Francis
Milwaukee, WI
1-star overall rating with 1-star inspections with $175,897 in total fines with 39 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
St Ann Health And Rehabilitation Center
Milwaukee, WI
3-star overall rating with 4-star inspections with 4 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Autumn Lake Healthcare At Greenfield
Milwaukee, WI
1-star overall rating with 1-star inspections with abuse icon flag with $176,440 in total fines with 28 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Jump out