01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-08-04 | 12 | 2025-08-04 | 7 |
| Cycle 2 | 2024-05-01 | 31 | 2024-05-01 | 10 |
| Cycle 3 | 2023-03-23 | 3 | 2023-03-23 | 9 |
CMS CCN 5254152026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Menomonee Falls Health Services
N84 W17049 Menomonee Ave · Menomonee Falls, WI 53051 · Waukesha County
Certified beds50CMS provider file
Recent citation rows72current CMS citation release
Penalty rows6current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
72 rows in the current release
5 rows carry G–L scope/severity codes; 0 carry J–L. 14 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-03 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2025-12-08 · complaint2025-08-04 · FIREE0013Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop Emergency Preparedness policies and procedures.
Correction field: Deficient, Provider has date of correction · 2025-08-252025-08-04 · HEALTHF0607Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2025-08-262025-08-04 · HEALTHF0628Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2025-08-262025-08-04 · HEALTHF0641Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-08-262025-08-04 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-08-262025-08-04 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-08-262025-08-04 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-08-262025-08-04 · HEALTHF0849Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-08-262025-08-04 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-09-032025-08-04 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2025-08-302025-08-04 · HEALTHF0887Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Correction field: Deficient, Provider has date of correction · 2025-08-302025-08-04 · HEALTHF0947Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Correction field: Deficient, Provider has date of correction · 2025-08-262025-08-04 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-08-222025-08-04 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-08-222025-08-04 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-08-222025-08-04 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-08-262025-08-04 · FIREK0712Severity C · widespread; potential for minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-08-252025-08-04 · FIREK0741Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2025-08-282024-11-26 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2024-12-24 · complaint2024-11-26 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-12-24 · complaint2024-11-26 · HEALTHF0685Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Correction field: Deficient, Provider has date of correction · 2024-12-24 · complaint2024-11-26 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-12-24 · complaint2024-11-26 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-12-24 · complaint03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-08-04 | Fine | $94,680 | 0 |
| 2024-11-26 | Fine | $31,103 | 0 |
| 2024-05-01 | Fine | $55,419 | 0 |
| 2024-05-01 | Payment Denial | $0 | 8 |
| 2023-12-18 | Fine | $29,961 | 0 |
| 2023-12-11 | Fine | $3,145 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- NSHF OPERATIONS LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 07/24/2017
- MILLS, DAVIDIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST20% · since 06/29/2017
- CIBC BANK USAOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 12/31/2024
- BAUMANN, TROYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/29/2017
- HOEHN, JEFFREYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/29/2017
- CIBC BANK USAOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/31/2024
- CLIFTONLARSONALLEN LLPOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/22/2018
- CONTINUUM THERAPY PARTNERS LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/01/2025
- NORTH SHORE HEALTHCARE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2017
- NSH REHAB LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/01/2025
- WIPFLI LLPOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2025
- BAUMANN, TROYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2017
- BELONGIA, CHRISTINAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2019
- GEE, DARRENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/30/2021
- GREER, LAURENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/29/2023
- GROSENICK, KARIIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/06/2025
- HOEHN, JEFFREYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2017
- PATZER, COLLEENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/14/2023
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.63per resident day
RN hours0.62per resident day
Weekend nurse hours3.39per resident day
Staff turnover38.7%CMS reported field
06 / LOCAL RECORDS
Open the Menomonee Falls ledger →