Cycle 1
Health 2025-07-24 · Fire 2025-07-24
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Services (3 deficiencies)
Milwaukee, WI
Sunrise Health Services
1-star overall rating with 1-star inspections with $113,910 in total fines with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
3540 S 43rd St, Milwaukee, WI
(414) 541-1000
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
99
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1992-08-01
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
0.53
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.12
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,330
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9844
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.39
Baseline 16.58% · Performance 20.33% · Measure score 2.39 · Achievement 2.39 · Improvement 0
Healthcare-associated infections
0
Baseline 5.86% · Performance 8.27% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.93
Baseline 24.53% · Performance 35.37% · Measure score 6.93 · Achievement 6.93 · Improvement 0
Adjusted total nurse staffing
1.52
Baseline 2.98 hours · Performance 3.51 hours · Measure score 1.52 · Achievement 1.52 · Improvement 1.41
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.05% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 15.91% · Lower 95% interval 9.28% |
| Discharge to community | 57.7% |
50.57%
7.1 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 51.9% · Lower 95% interval 47.58% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.67% |
95.27%
3.4 pts better
|
Numerator 74 · Denominator 75 |
| Falls with major injury | 2.67% |
0.77%
1.9 pts worse
|
Numerator 2 · Denominator 75 |
| Discharge self-care score | 47.37% |
53.69%
6.3 pts worse
|
Numerator 27 · Denominator 57 |
| Discharge mobility score | 47.37% |
50.94%
3.6 pts worse
|
Numerator 27 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 1.33% |
2.29%
1 pts better
|
Numerator 1 · Denominator 75 · Adjusted rate 1.41% |
| Healthcare-associated infections requiring hospitalization | 8.26% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 12.28% · Lower 95% interval 5.47% |
| Staff COVID-19 vaccination coverage | 2% |
8.2%
6.2 pts worse
|
Numerator 1 · Denominator 50 |
| Staff flu vaccination coverage | 24.73% |
42%
17.3 pts worse
|
Numerator 23 · Denominator 93 |
| Discharge function score | 57.89% |
56.45%
1.4 pts better
|
Numerator 33 · Denominator 57 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 92.68% |
96.28%
3.6 pts worse
|
Numerator 38 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 21.05% |
25.2%
4.1 pts worse
|
Numerator 8 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.2
0.1 pts better
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
95.7%
5.5 pts worse
|
93.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.2% · Q2 91.9% · Q3 89.7% · Q4 89.9% · 4Q avg 90.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.7% |
95.0%
4.3 pts worse
|
95.5%
4.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.2%
0.2 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 5.1% · Q4 3.8% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
5.0%
3.9 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 1.4% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
4.9%
2.2 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 6.0% · Q4 1.4% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.6% |
16.6%
3 pts worse
|
19.6%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 22.2% · Q3 16.2% · Q4 18.3% · 4Q avg 19.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
16.7%
6.2 pts better
|
16.7%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 10.0% · Q3 11.5% · Q4 10.3% · 4Q avg 10.5% · 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 | 29.0% |
21.1%
7.9 pts worse
|
16.3%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 31.4% · Q3 35.2% · Q4 26.2% · 4Q avg 29.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
17.3%
1.7 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 13.6% · Q3 27.7% · Q4 17.6% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
2.3%
1.3 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
3.0%
0.3 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.2% · Q3 2.6% · Q4 3.9% · 4Q avg 3.3% · 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 20.9% · Q2 34.0% · Q3 24.0% · Q4 16.0% · 4Q avg 23.7% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
5.5%
0.8 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 7.9% · Q3 6.0% · Q4 2.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.4% |
86.8%
7.4 pts worse
|
81.7%
2.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 79.6% · Q2 81.3% · Q3 78.5% · Q4 77.6% · 4Q avg 79.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.8% |
15.0%
2.2 pts better
|
12.0%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.8% · Observed 13.2% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.4% |
82.2%
22.8 pts worse
|
79.7%
20.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
22.7%
3.2 pts worse
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 25.0% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-04 · Fire 2024-04-04
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2023-01-17 · Fire 2023-01-17
14 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-09-15
E · Potential for more than minimal harm
2025-07-24
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-08-11
E · Potential for more than minimal harm
2025-07-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-19
E · Potential for more than minimal harm
2025-07-24
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-07-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-08-08
C · Minimal harm
2025-07-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-30
F · Potential for more than minimal harm
2024-04-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-12
F · Potential for more than minimal harm
2024-04-04
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-04-04
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-04
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-04
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 2024-05-03
C · Minimal harm
2024-04-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-03
F · Potential for more than minimal harm
2023-01-17
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-02-15
F · Potential for more than minimal harm
2023-01-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-15
F · Potential for more than minimal harm
2023-01-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-15
F · Potential for more than minimal harm
2023-01-17
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-02-15
F · Potential for more than minimal harm
2023-01-17
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-02-23
E · Potential for more than minimal harm
2023-01-17
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 2023-02-15
E · Potential for more than minimal harm
2023-01-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-15
E · Potential for more than minimal harm
2023-01-17
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-02-15
D · Potential for more than minimal harm
2023-01-17
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-02-23
D · Potential for more than minimal harm
2023-01-17
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 2023-02-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-24
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-07-24
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 2025-08-22
D · Potential for more than minimal harm
2025-07-24
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 2025-08-22
D · Potential for more than minimal harm
2025-07-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-24
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 2025-08-22
D · Potential for more than minimal harm
2025-07-24
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 2025-08-22
D · Potential for more than minimal harm
2025-07-24
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 2025-08-22
E · Potential for more than minimal harm
2025-07-01
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-07-18
J · Immediate jeopardy
2025-03-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-15
E · Potential for more than minimal harm
2025-03-19
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-03-19
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 2025-04-15
D · Potential for more than minimal harm
2025-03-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-03-19
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 2025-04-15
D · Potential for more than minimal harm
2025-03-19
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 2025-04-15
J · Immediate jeopardy
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 2024-05-29
J · Immediate jeopardy
2024-05-01
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-05-01
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 2024-05-29
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 2024-05-29
D · Potential for more than minimal harm
2024-05-01
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-05-29
F · Potential for more than minimal harm
2024-04-04
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-04-04
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 2024-05-03
D · Potential for more than minimal harm
2024-04-04
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-04
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 2024-05-03
C · Minimal harm
2024-04-04
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 2024-05-03
D · Potential for more than minimal harm
2024-01-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-06
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 2024-02-05
E · Potential for more than minimal harm
2023-08-31
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-08-31
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-09-27
E · Potential for more than minimal harm
2023-01-17
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 2023-02-15
E · Potential for more than minimal harm
2023-01-17
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 2023-02-15
D · Potential for more than minimal harm
2023-01-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-02-15
D · Potential for more than minimal harm
2023-01-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-15
D · Potential for more than minimal harm
2023-01-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-15
D · Potential for more than minimal harm
2023-01-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-15
D · Potential for more than minimal harm
2023-01-17
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-02-15
D · Potential for more than minimal harm
2023-01-17
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-02-15
D · Potential for more than minimal harm
2023-01-17
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 2023-02-15
D · Potential for more than minimal harm
2023-01-17
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 2023-02-15
Penalties and ownership
What sits behind the stars
$83,067
2025-03-19
Fine
Fine · fine $83,067
Fine
$30,843
2024-04-04
Fine
Fine · fine $30,843
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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