Menomonee Falls Health Services
Menomonee Falls, Wisconsin · CCN 525415
34 surveys since 2010, 22 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 219
- Surveys
- 34
- Harm or worse
- 22
- Immediate jeopardy
- 9
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 50
- Ownership
- For profit - Limited Liability company
- Chain
- NORTH SHORE HEALTHCARE
- County
- Waukesha
- Medicare-certified since
- 1988
CMS ratings
- Overall
- 2
- Health inspection
- 2
- Staffing
- 3
- Quality measures
- 3
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 92 for-profit facilities with fewer than 66 beds in Wisconsin.
Last survey on record
Dec 3, 2025
341 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.63 | 3.73 |
| Registered-nurse hours per resident day | 0.62 | — |
| Annual nurse turnover | 38.7% | 45.7% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $214,308 across 5 penalties
- Payment denials
- 1
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G510.9% | H— | I— |
| No harm, potential for more than minimal | D2963.0% | E510.9% | F715.2% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6864×
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- F5542×
Allow residents to self-administer drugs if determined clinically appropriate.
- F6842×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F6892×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F7612×
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.
In the surveyor’s words
From the most serious findings on record at Menomonee Falls Health Services, in the surveyor’s own words.
- Immediate jeopardy, isolatedF580Oct 14, 2021
Based on interview and record review, the Facility did not immediately consult with a physician from general surgery when ordered and did not inform the resident's representative of the condition change and need for surgical consult for 1 (R5) of 6 Residents reviewed for notification. On 9/20/20 facility staff identified a mass on R5's left thigh. The physician gave orders for a consult with a physician from general surgery. The facility did not consult with a general surgeon and get an appointment. The facility did not inform the Health Care Power of Attorney, who is actively involved in her brother's care, about the left thigh mass and the order for a consult for general surgery. On 3/15/21 the facility again identified the left thigh mass when doing a skin sweep. […]
- Immediate jeopardy, isolatedF684Oct 14, 2021
Based on interview and record review the facility did not ensure 1 (R5) of 6 Residents reviewed received care and treatment in accordance with their physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Nurse Practitioner (NP) note dated 9/29/20 documents under assessment and plan, Left Thigh Mass - patient notes duration is 8 months - non-tender, non-mobile. firm -will refer to general surgery. Under physical exam for extremities documents, No [CONDITION(S)] noted. Not cyanotic. left thigh mass. There are no measurements of the left thigh mass and no revisions in R5's skin integrity care plan. The order administration note dated 9/29/20 documents, Consult to general surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Will obtain. […]
- Immediate jeopardy, isolatedF686Jul 27, 2021
Based on interview, record review and observation, the facility did not ensure that a resident who entered the facility without a Pressure Injury (PI) did not develop a PI and received appropriate care, treatment and preventative measures to promote healing for 2 (R3 & R6) of 3 Residents reviewed for pressure injuries. R3 was admitted to the facility on [DATE] for short term rehab without any pressure injuries. On 2/7/21, R3 was identified with a small open area. There was no assessment of this open area. The weekly skin review dated 2/11/21 noted R3 had a previously existing pressure injury to the coccyx but no other open areas. There was no assessment of R3's pressure injury on 2/11/21. […]
- Actual harm, isolatedF689Aug 4, 2025
Based on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 4 of 6 residents (R6, R1, R10, and R22) reviewed for accidents. * On 2/13/2025, a Certified Nursing Assistant (CNA) transferred R6 not according to R6’s plan of care and bumped R6’s leg. R6 required surgical intervention to R6’s right leg as a result of the CNA not following R6’s plan of care for transferring. * R1 had a fall on 4/11/2025 and no documentation was located that the facility did a thorough investigation. * R22 had a fall out of bed when staff did not follow R22’s plan of care. R22 was receiving cares with assist of one when R22 rolled out of bed. R22’s plan of care was to have assist of 2. […]
- Actual harm, isolatedF686Nov 26, 2024
Based on observations, interviews, and record review, the facility did not ensure that residents with pressure injuries received the necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 of 2 residents (R5 and R7) reviewed. * R5, who was assessed to be at risk for pressure injuries, developed a stage 3 ischium pressure injury identified on 11/21/24. R5's care plan was not updated with new offloading interventions after the development of the ischium pressure injury. On 11/21/24, Wound Doctor (WD)-H recommended to upgrade offloading chair cushion. This was not completed by the facility. WD-H's treatment orders were not initiated until 11/26/24. […]
Read 38 findings in full →The most serious and the most recent: 38 of 219 on record.
Every survey on record
FindingsAt actual harm or above
- Dec 3, 2025Complaint1 finding
- Aug 4, 2025Standard11 findings · 1 harm
- Nov 26, 2024Complaint5 findings · 1 harm
- May 1, 2024Standard and complaint26 findings · 2 harm
- Dec 18, 2023Complaint2 findings · 1 harm
- Mar 23, 2023Standard and complaint5 findings
- Aug 19, 2022Complaint1 finding
- Jan 6, 2022Standard5 findings
Show the 26 earlier surveys
- Oct 14, 2021Complaint9 findings · 2 harm
- Jul 27, 2021Complaint7 findings · 1 harm
- Mar 16, 2021Complaint1 finding
- Jul 29, 2020Complaint5 findings · 1 harm
- Sep 25, 2019Standard11 findings
- Mar 6, 2019Complaint2 findings
- Aug 7, 2018Standard and complaint8 findings · 1 harm
- Mar 27, 2018Complaint6 findings
- Jun 27, 2017Standard3 findings
- Sep 28, 2016Complaint5 findings · 1 harm
- Mar 22, 2016Standard and complaint17 findings
- Oct 15, 2015Complaint6 findings
- Jan 28, 2015Standard and complaint7 findings · 2 harm
- Dec 8, 2014Standard and complaint29 findings · 3 harm
- Sep 4, 2014Complaint3 findings · 3 harm
- Apr 7, 2014Complaint1 finding
- Oct 3, 2013—8 findings
- Sep 11, 2013—1 finding
- Aug 12, 2013—1 finding
- Apr 16, 2013—1 finding
- Feb 20, 2013—5 findings · 1 harm
- Aug 16, 2012—15 findings · 1 harm
- Aug 8, 2011—7 findings
- May 13, 2011—1 finding
- Feb 3, 2011—2 findings
- Sep 16, 2010—2 findings · 1 harm
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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