Nursing Care Index

Mercy Health Services

Milwaukee, Milwaukee County, Wisconsin · CCN 525414 · For-profit (Corporation) · part of North Shore Healthcare (59 facilities, chain average 2.7 stars)

CMS rates Mercy Health Services 3 of 5 overall as of August 2026. 60 certified beds, 44 residents a day on average. 32 citations on record from the current inspection cycles, 2 involving actual harm; 2 fines totalling $47,753.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★★★☆☆ 3 of 5
Health inspections★★★☆☆ 3 of 5
Staffing★★☆☆☆ 2 of 5
Quality measures★★☆☆☆ 2 of 5
Quality: long-stay / short-stay2 / 3 of 5

Staffing

Total nurse staffing3.73132 hours per resident per day
Registered nurses0.63935 hours per resident per day
Weekend total3.28699 hours per resident per day
Nursing staff turnover62.3% (registered nurses 61.5%)
Administrators who left1

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-03-02
complaint survey
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-18
2025-12-03
complaint survey
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-16
2025-12-03
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-16
2025-05-21 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies · tag F0628
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-06-21
2025-05-21
complaint survey
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · tag F0757
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-06-21
2025-05-21 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies · tag F0805
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-06-21
2024-09-19
complaint survey
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-10-18
2024-09-19
complaint survey
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · tag F0584
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-18
2024-09-19
complaint survey
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-18
2024-08-05
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-09-04
2024-08-05
complaint survey
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-09-04
2024-05-13
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-06-07
2024-02-29 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-04-01
2024-02-29
complaint survey
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.
Resident Rights Deficiencies · tag F0578
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-01
2024-02-29
complaint survey
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-01
2024-02-29
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-01
2024-02-29
complaint survey
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-01
2024-02-29 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-01
2024-02-29 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.
Pharmacy Service Deficiencies · tag F0758
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-01
2024-02-29 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-01
2024-02-29 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-01
2022-12-21 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Nursing and Physician Services Deficiencies · tag F0727
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-01-26
2022-12-21 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-01-26
2022-12-21 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Nursing and Physician Services Deficiencies · tag F0947
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-01-26
2022-12-21 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-01-26
2022-12-21 Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · tag F0554
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-01-26
2022-12-21 PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · tag F0645
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-01-26
2022-12-21 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-01-26
2022-12-21 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-01-26
2022-12-21 Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0698
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-01-26
2022-12-21 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.
Quality of Life and Care Deficiencies · tag F0700
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-01-26
2022-12-21 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-01-26

Fines and payment denials

DatePenaltyAmount
2024-05-13Fine$14,050
2024-02-29Fine$33,703

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Nshf Operations LLC
Organization
5% or greater direct ownership interest100%2017-07-24
Cibc Bank USA
Organization
5% or greater security interest2024-12-31
Cliftonlarsonallen LLP
Organization
adp of the snf2025-04-15
Continuum Therapy Partners LLC
Organization
adp of the snf2025-04-15
Mercy Property Holdings, LLC
Organization
adp of the snf2022-05-01
North Shore Healthcare LLC
Organization
adp of the snf2025-04-15
Nsh Rehab LLC
Organization
adp of the snf2025-06-11
Nshf Wisconsin LLC
Organization
adp of the snf2025-11-05
Wipfli LLP
Organization
adp of the snf2025-04-15
Cibc Bank USA
Organization
operational/managerial control2024-12-31
Cliftonlarsonallen LLP
Organization
operational/managerial control2018-05-22
Continuum Therapy Partners LLC
Organization
operational/managerial control2025-03-01
North Shore Healthcare LLC
Organization
operational/managerial control2017-10-01
Nsh Rehab LLC
Organization
operational/managerial control2025-03-01
Wipfli LLP
Organization
operational/managerial control2025-02-01
Mills, David
Individual
5% or greater indirect ownership interest20%2017-06-29
Baumann, Troy
Individual
adp of the snf2017-10-01
Belongia, Christina
Individual
adp of the snf2019-11-01
Chohan, Muniba
Individual
adp of the snf2023-01-01
Gee, Darren
Individual
adp of the snf2021-11-30
Greer, Lauren
Individual
adp of the snf2023-11-29
Hoehn, Jeffrey
Individual
adp of the snf2017-10-01
Patzer, Colleen
Individual
adp of the snf2023-02-14
Purtell, Brian
Individual
adp of the snf2018-06-01
Rivera, Edward
Individual
adp of the snf2026-06-08
Baumann, Troy
Individual
corporate director2017-06-29
Hoehn, Jeffrey
Individual
corporate director2017-06-29
Baumann, Troy
Individual
operational/managerial control2017-10-01
Belongia, Christina
Individual
operational/managerial control2019-11-01
Chohan, Muniba
Individual
operational/managerial control2023-01-01
Gee, Darren
Individual
operational/managerial control2021-11-30
Greer, Lauren
Individual
operational/managerial control2023-11-29
Hoehn, Jeffrey
Individual
operational/managerial control2017-10-01
Patzer, Colleen
Individual
operational/managerial control2023-02-14
Purtell, Brian
Individual
operational/managerial control2018-06-01
Rivera, Edward
Individual
operational/managerial control2026-06-08

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Milwaukee County.