Mercy Health Services
Milwaukee, Wisconsin · CCN 525414
31 surveys since 2011. The first finding at harm level was recorded in 2017.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 119
- Surveys
- 31
- Harm or worse
- 10
- Immediate jeopardy
- 4
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
- 60
- Ownership
- For profit - Corporation
- Chain
- NORTH SHORE HEALTHCARE
- County
- Milwaukee
- Medicare-certified since
- 1988
CMS ratings
- Overall
- 3
- Health inspection
- 3
- Staffing
- 2
- Quality measures
- 2
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
Mar 2, 2026
252 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 | 3.73 | 3.73 |
| Registered-nurse hours per resident day | 0.64 | — |
| Annual nurse turnover | 62.3% | 45.7% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $47,753 across 2 penalties
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 | G26.3% | H— | I— |
| No harm, potential for more than minimal | D2475.0% | E39.4% | F39.4% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6093×
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- F6103×
Respond appropriately to all alleged violations.
- F7552×
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- F7592×
Ensure medication error rates are not 5 percent or greater.
- F8802×
Provide and implement an infection prevention and control program.
In the surveyor’s words
From the most serious findings on record at Mercy Health Services, in the surveyor’s own words.
- Immediate jeopardy, widespreadF880Feb 22, 2023
Based on observations, interviews and record review, the facility did not implement an effective infection control and prevention program before, and during a COVID outbreak in the facility. This deficient practice has the potential to affect all 49 residents who reside in the facility. As of 2/22/23 the facility was having a COVID-19 outbreak with 10 staff and 24 of their 49 residents positive for COVID-19. The outbreak began on 2/9/23 with 2 residents (R2 and R3) testing positive. R2 and R3 ate in the communal dining room until they tested positive for COVID-19. On 2/9/23, the facility did not implement infection control measures to stop the transmission of COVID-19. […]
- Immediate jeopardy, widespreadF882Feb 22, 2023
Based on observations, interviews and record review, the facility did not ensure the Infection Preventionist had adequate time to fulfill the responsibilities of the position. DON-B (Director of Nurses) is designated as the facility's Infection Preventionist (IP) in addition to performing full-time DON duties which resulted in the inability to implement an effective Infection Control and Prevention Program. The Infection Preventionist did not implement, monitor, and manage the Infection Control program's policy and procedures related to transmission of COVID-19. On 2/9/23 the facility had an initial onsite of a COVID-19 outbreak. As of 2/22/23, 10 staff and 24 of 49 residents residing in the facility were positive for COVID-19. […]
- Immediate jeopardy, isolatedF580Sep 13, 2021
Based on interview, record review and observation, the facility did not consult with the resident's physician regarding an anticoagulant (medication that thins the blood) for 1 of 1 (R23) residents reviewed for anticoagulants not being adequately monitored for therapeutic levels or that an ordered medication was not available. R23 was admitted to the facility on [DATE] with orders for [MEDICATION(S)]/[MEDICATION(S)] (an anticoagulant) medication [MEDICATION(S)] and PT/INR for monitoring for a therapeutic level of INR 2 to 2.5. R23 was receiving [MEDICATION(S)] 3.5 mg, which was on hold from [DATE] to [DATE], and a PT/INR was ordered to be drawn on [DATE]. The facility did not follow up with lab regarding the ordered lab PT/INR and began administering [MEDICATION(S)] 3.5 mg on [DATE]. […]
- Immediate jeopardy, isolatedF757Sep 13, 2021
Based on interview, record review and observation, the facility failed to ensure that 1 (R23) of 1 residents reviewed for anticoagulants was adequately monitored for therapeutic levels. R23 was admitted to the facility on [DATE] with orders for [MEDICATION(S)]/[MEDICATION(S)] (an anticoagulant) and PT/INR for monitoring for a therapeutic level of INR 2 to 2.5. R23 was receiving [MEDICATION(S)] 3.5 mg, which was on hold from [DATE] to [DATE], and a PT/INR was ordered to be drawn on [DATE]. The facility did not follow up with lab regarding the ordered lab PT/INR and began administering [MEDICATION(S)] 3.5 mg on [DATE] using the physician's previous order prior to the [MEDICATION(S)] being placed on hold. R23 received [MEDICATION(S)] 3.5 mg each day from [DATE] to [DATE]. […]
- Actual harm, isolatedF689May 13, 2024
Based on observation, interview, and record review the Facility did not ensure each Resident received adequate supervision and assistance devices to prevent accidents for 2 (R1 & R2) of 3 Residents reviewed for accidents. *R1 was assessed to require one-to-one staff supervision. R1 was left unattended and sustained a fall on 04/16/2024 that resulted in multiple fractures. Surveyor had observations of R1 not having fall prevention interventions in place of antiroll back equipment or a fall mat in place as documented in the care plan. *R2 was observed to not have current fall prevention interventions of auto lock brakes and Dycem in place. Findings include: The facility's policy titled:NSG (nursing) Accidents and Supervision with a last revision date of 07/04/2022, documents, . 3. […]
Read 28 findings in full →The most serious and the most recent: 28 of 119 on record.
Every survey on record
FindingsAt actual harm or above
- Aug 17, 2026Complaint7 findings
- Mar 2, 2026Complaint1 finding
- Dec 3, 2025Complaint2 findings
- May 21, 2025Standard and complaint3 findings
- Sep 19, 2024Complaint3 findings
- Aug 5, 2024Complaint2 findings
- May 13, 2024Complaint1 finding · 1 harm
- Feb 29, 2024Standard and complaint9 findings · 1 harm
Show the 23 earlier surveys
- Feb 22, 2023Infection control3 findings · 2 harm
- Dec 21, 2022Standard11 findings
- Oct 7, 2022Complaint1 finding
- Jun 7, 2022Complaint4 findings
- Sep 13, 2021Standard7 findings · 4 harm
- Jul 27, 2021Complaint7 findings
- Mar 30, 2021Complaint1 finding
- Nov 2, 2020Complaint1 finding · 1 harm
- Sep 9, 2020Complaint1 finding
- Jan 28, 2020Complaint1 finding
- Oct 8, 2019Standard and complaint12 findings
- Nov 29, 2018Standard7 findings
- Oct 19, 2017Standard13 findings
- Mar 13, 2017Complaint1 finding · 1 harm
- Jun 30, 2016Standard and complaint2 findings
- Mar 30, 2015Standard and complaint7 findings
- Jan 30, 2014Standard and complaint2 findings
- Jun 26, 2013—1 finding
- May 7, 2012—1 finding
- Mar 5, 2012—2 findings
- Dec 13, 2011—3 findings
- Apr 21, 2011—1 finding
- Feb 14, 2011—2 findings
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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