WILLOWCREST HEALTH SERVICES

SOUTH MILWAUKEE, WI · 100 beds · For profit - Limited Liability company

0 Trust Score
Grade: F CRITICAL Risk → Stable

Red Flags

  • 1-star staffing rating
  • 2 citation(s) at the highest severity level — immediate risk to residents
  • RN hours significantly below state average

Green Flags

No positive signals identified yet.

Quick Facts

★★☆☆☆
CMS Overall
★★☆☆☆
Health Inspection
14
1.4x state avg
Deficiencies
$21,285
Fines (3-yr)
★☆☆☆☆
Staffing

Violation Timeline

June 4, 2025

20 deficiencyies
F0880 Potential Harm Scope/Severity: F

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

F0605 Potential Harm Scope/Severity: D

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

F0628 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

F0684 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide appropriate treatment and care according to orders, resident’s preferences and goals.

F0688 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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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.

F0690 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

F0693 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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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.

F0880 Potential Harm Scope/Severity: F

Infection Control Deficiencies

Show details

Provide and implement an infection prevention and control program.

F0605 Potential Harm Scope/Severity: D

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Show details

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

F0628 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

Show details

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

F0684 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

F0688 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

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.

F0690 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

F0693 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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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.

F0695 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide safe and appropriate respiratory care for a resident when needed.

F0699 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide care or services that was trauma informed and/or culturally competent.

F0755 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

F0757 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure each resident’s drug regimen must be free from unnecessary drugs.

F0760 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure that residents are free from significant medication errors.

F0851 Potential Harm Scope/Severity: F

Administration Deficiencies

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Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

See full violation history →

Staffing

0.50
RN hrs/res/day
0.92
LPN hrs/res/day
1.80
CNA hrs/res/day
2.84
Weekend hrs/res/day
55%
Total nurse turnover
67%
RN turnover

A nurse checks on each resident roughly every 7.5 hours on average.

Fines & Penalties

  • Fine Mar 28, 2024
    $21,285
Total $21,285

Ownership

For profit - Limited Liability company Chain: NORTH SHORE HEALTHCARE
  • NSHF OPERATIONS LLC

    5% OR GREATER DIRECT OWNERSHIP INTEREST

    Since since 07/24/2017

    100% Organization
  • BAUMANN, TROY

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 06/29/2017

    40% Individual
  • HOEHN, JEFFREY

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 06/29/2017

    40% Individual
  • MILLS, DAVID

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 06/29/2017

    20% Individual
  • NORTH SHORE HEALTHCARE LLC

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 10/01/2017

    Organization
  • BAUMANN, TROY

    CORPORATE DIRECTOR

    Since since 06/29/2017

    Individual
  • HOEHN, JEFFREY

    CORPORATE DIRECTOR

    Since since 06/29/2017

    Individual
  • HOEHN, JEFFREY

    W-2 MANAGING EMPLOYEE

    Since since 06/29/2017

    Individual

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