Cycle 1
Health 2025-06-05 · Fire 2025-06-05
14 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
South Milwaukee, WI
Willowcrest Health Services
2-star overall rating with 2-star inspections with $21,285 in total fines with 14 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
3821 S Chicago Ave, South Milwaukee, WI
(414) 762-7336
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1988-07-21
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
0.97
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.40
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.22
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,016
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.55
Baseline 19.91% · Performance 20.71% · Measure score 1.55 · Achievement 1.55 · Improvement 0
Healthcare-associated infections
2.80
Baseline 6.77% · Performance 7.00% · Measure score 2.80 · Achievement 2.80 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
1.15
Baseline 3.62 hours · Performance 3.40 hours · Measure score 1.15 · Achievement 1.15 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.68% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 152 · Observed rate 11.84% · Lower 95% interval 7.54% |
| Discharge to community | 58.53% |
50.57%
8 pts better
|
Better than the National Rate · Eligible stays 138 · Observed rate 50.72% · Lower 95% interval 51.23% |
| Medicare spending per beneficiary | 0.81 |
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 | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 75 |
| Discharge self-care score | 54.72% |
53.69%
1 pts better
|
Numerator 29 · Denominator 53 |
| Discharge mobility score | 56.6% |
50.94%
5.7 pts better
|
Numerator 30 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 1.33% |
2.29%
1 pts better
|
Numerator 1 · Denominator 75 · Adjusted rate 1.12% |
| Healthcare-associated infections requiring hospitalization | 7% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 7.23% · Lower 95% interval 3.74% |
| Staff COVID-19 vaccination coverage | 2.94% |
8.2%
5.3 pts worse
|
Numerator 3 · Denominator 102 |
| Staff flu vaccination coverage | 40.2% |
42%
1.8 pts worse
|
Numerator 41 · Denominator 102 |
| Discharge function score | 60.38% |
56.45%
3.9 pts better
|
Numerator 32 · Denominator 53 |
| Transfer of health information to provider | 97.67% |
95.95%
1.7 pts better
|
Numerator 42 · Denominator 43 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 27.91% |
25.2%
2.7 pts better
|
Numerator 12 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
95.7%
1.4 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 95.2% · Q3 96.7% · Q4 98.4% · 4Q avg 97.1% |
| 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 | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 1.6% · Q3 0.0% · Q4 1.6% · 4Q avg 2.0% · 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 | 3.8% |
4.9%
1.1 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.1% · Q3 1.9% · Q4 3.5% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.4% |
16.6%
3.2 pts better
|
19.6%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 15.7% · Q3 14.8% · Q4 10.3% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.0% |
16.7%
6.7 pts better
|
16.7%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 10.3% · Q3 6.5% · Q4 8.2% · 4Q avg 10.0% · 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 | 45.2% |
21.1%
24.1 pts worse
|
16.3%
28.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 45.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.8% |
17.3%
0.5 pts worse
|
14.9%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 19.1% · Q3 21.6% · Q4 15.1% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
2.3%
0.5 pts better
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.9% · Q3 1.8% · Q4 1.5% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
3.0%
2.6 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.5% |
25.5%
2 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 18.6% · Q3 30.9% · Q4 25.8% · 4Q avg 27.5% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.5%
1.1 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 2.8% · Q3 5.0% · Q4 3.8% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
86.8%
7.2 pts better
|
81.7%
12.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.6% · Q2 93.8% · Q3 96.9% · Q4 95.0% · 4Q avg 94.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
15.0%
7 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 7.5% · 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 | 94.0% |
82.2%
11.8 pts better
|
79.7%
14.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.4% |
22.7%
7.7 pts worse
|
23.9%
6.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.4% · Observed 28.3% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-29 · Fire 2024-03-29
18 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
9 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
2025-06-05
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-07-05
F · Potential for more than minimal harm
2025-06-05
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 2025-07-05
F · Potential for more than minimal harm
2025-06-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-08-28
F · Potential for more than minimal harm
2025-06-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-05
F · Potential for more than minimal harm
2025-06-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-05
F · Potential for more than minimal harm
2025-06-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-05
E · Potential for more than minimal harm
2025-06-05
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 2025-07-05
E · Potential for more than minimal harm
2025-06-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-05
F · Potential for more than minimal harm
2024-03-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-03-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-03-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-03-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-30
F · Potential for more than minimal harm
2024-03-29
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-08-30
F · Potential for more than minimal harm
2024-03-29
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 2024-04-26
E · Potential for more than minimal harm
2024-03-29
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 2024-09-30
E · Potential for more than minimal harm
2024-03-29
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 2024-09-30
E · Potential for more than minimal harm
2024-03-29
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 2024-04-26
D · Potential for more than minimal harm
2024-03-29
K233 · Egress Deficiencies
Fire Safety
Install resident room doors of proper design and width.
Corrected 2024-04-26
F · Potential for more than minimal harm
2023-01-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-10
F · Potential for more than minimal harm
2023-01-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-01-12
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 2023-02-10
E · Potential for more than minimal harm
2023-01-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-01-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-01-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-01-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-01-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-12
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 2023-02-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-05
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-07-05
F · Potential for more than minimal harm
2025-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
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 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
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 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-03-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-31
C · Minimal harm
2024-10-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-12
J · Immediate jeopardy
2024-03-29
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 2024-04-26
J · Immediate jeopardy
2024-03-29
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 2024-04-26
F · Potential for more than minimal harm
2024-03-29
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 2024-04-26
F · Potential for more than minimal harm
2024-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-29
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-29
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-29
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-29
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-29
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 2024-04-26
D · Potential for more than minimal harm
2024-03-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-29
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-29
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-29
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 2024-04-26
D · Potential for more than minimal harm
2024-03-29
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 2024-04-26
B · Minimal harm
2024-03-29
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 2024-04-26
F · Potential for more than minimal harm
2023-01-12
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 2023-02-10
E · Potential for more than minimal harm
2023-01-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-12
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 2023-02-10
Penalties and ownership
What sits behind the stars
$21,285
2024-03-29
Fine
Fine · fine $21,285
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
Nearby options
Other facilities in reach
#1
Chi Franciscan Villa
South Milwaukee, WI
1-star overall rating with 1-star inspections with abuse icon flag with $271,775 in total fines with 20 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#2
Medical Suites At Oak Creek (The)
Oak Creek, WI
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $187,064 in total fines with 33 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Maple Ridge Health Services
Milwaukee, WI
2-star overall rating with 3-star inspections with $14,433 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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