Monroe Health Services
Monroe, Wisconsin · CCN 525292
31 surveys since 2010, 11 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
- 154
- Surveys
- 31
- Harm or worse
- 11
- Immediate jeopardy
- 6
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
- Green
- Medicare-certified since
- 1978
CMS ratings
- Overall
- 4
- Health inspection
- 4
- Staffing
- 4
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat fewer weighted findings than 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 | 3.64 | 3.73 |
| Registered-nurse hours per resident day | 0.84 | — |
| Annual nurse turnover | 48.1% | 45.7% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D2090.9% | E— | F29.1% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F5803×
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- F6862×
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- F8122×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F5571×
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- F5601×
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
In the surveyor’s words
From the most serious findings on record at Monroe Health Services, in the surveyor’s own words.
- Immediate jeopardy, isolatedF689Mar 29, 2022
Based on observation, interview and record review, the facility did not ensure all residents who smoke did so safely and did not take immediate action when a resident was identified as smoking while wearing oxygen for 2 of 2 residents reviewed for smoking (R2 and R7). The facility's failure to implement safety and accident prevention measures for residents that smoke created a finding of immediate jeopardy that began on 12/11/21. The nursing Home Administrator (NHA A) was notified of the immediate jeopardy on 3/16/22 at approximately 2:15 PM. The immediate jeopardy was removed by the facility on 3/16/22. The deficient practice continues at a scope and severity of a D (potential for harm/isolated) as the facility continues to implement its action plan. […]
- Actual harm, isolatedF600Dec 15, 2021
Based on interview and record review, the facility did not ensure residents are free from verbal and mental abuse for 1 of 3 total residents (R1) from Certified Nursing Assistant (CNA) C, who would yell, slam doors, and complain. This resulted in psychosocial harm when R1 would not use his call light despite needing assistance with care because he wanted to avoid the feelings of intimidation, being afraid, being yelled at and talked down to, and being made to feel as if he was a burden. The facility did not have a system in place to ensure CNA C did not continue to abuse residents after the facility substantiated an allegation of abuse. CNA C was allowed to return to work and work alone with vulnerable elders despite the facility's substantiated findings of abuse. […]
- No harm, potential for more than minimal, widespreadF812Dec 3, 2025
Based on observation and interview, the facility did not store and prepare food in accordance with professional standards for food service safety. This has the potential to affect all 43 residents. Surveyor observed items opened and undated in the refrigerators and coolers. Surveyor observed food items unsealed and/or unmarked in the freezers. Surveyor observed food items in the freezer with visible freezer burn. Surveyor observed the facility's industrial stand mixer to be unclean. Surveyor observed an unclean ice bin. Surveyor observed staff sanitizing food thermometer with alcohol wipe without allowing it to dry before placing it in another food item during lunch service. Evidenced by: Facility policy, entitled General Food Preparation and Handling dated 8/16/22 states in part, . […]
- No harm, potential for more than minimal, widespreadF812Apr 25, 2023
Based on observation, interview, and record review, the facility did not ensure the preparation of food in a clean and sanitary environment with the potential to affect all 33 residents residing in the facility. Surveyor observed dust collecting on piping above food preparation area in the facility's stove hood unit. Surveyor observed a dust covered fan within 6 inches of food preparation area while food was being prepared. Surveyor observed a dust covered radio and desk top file folder holder above open prepared food. This is evidenced by: The facility policy, entitled Nutrition Services Practice Manual dated July 2015, states: .Promote a clean and sanitary environment for its employees, residents, and visitors. […]
- No harm, potential for more than minimal, patternF710Mar 29, 2022
Based on record review and interview the facility did not ensure that a physician personally approved in writing a recommendation that an individual be admitted to a facility, this affected 4 of 14 sampled residents. R7, R16, R19 and R125 were all admitted to the facility by a NP (Nurse Practitioner). This is evidenced by: Example 1 R7's Hospital Discharge Summary dated 6/8/21 documents, in part: .General Discharge Information .Discharge Disposition: Discharge to Skilled Nursing Facility, Discharge Provider .DNP (Doctor of Nursing Practice- which means the holder of this title is a Nurse Practitioner with a master's degree) . […]
Read 31 findings in full →The most serious and the most recent: 31 of 154 on record.
Every survey on record
FindingsAt actual harm or above
- Dec 3, 2025Standard4 findings
- Jan 17, 2025Complaint1 finding
- Nov 25, 2024Complaint1 finding
- Aug 8, 2024Complaint8 findings
- Feb 7, 2024Complaint3 findings
- Dec 6, 2023Complaint1 finding
- Apr 25, 2023Standard4 findings
- Sep 20, 2022Complaint1 finding
Show the 23 earlier surveys
- Mar 29, 2022Standard and complaint8 findings · 1 harm
- Dec 15, 2021Complaint1 finding · 1 harm
- Mar 12, 2020Standard and complaint4 findings
- Nov 26, 2019Complaint1 finding
- Feb 21, 2019Standard9 findings
- Jan 11, 2018Standard9 findings · 1 harm
- Nov 3, 2016Standard7 findings · 1 harm
- Jun 21, 2016Complaint1 finding
- Jan 22, 2016Complaint2 findings
- Sep 24, 2015Standard7 findings
- Mar 31, 2015Complaint4 findings
- Mar 4, 2015Complaint3 findings
- Jul 17, 2014Standard9 findings
- Feb 19, 2014Complaint4 findings
- Jul 2, 2013—2 findings · 2 harm
- May 13, 2013—20 findings · 3 harm
- Oct 1, 2012—6 findings
- Feb 23, 2012—12 findings · 1 harm
- Sep 29, 2011—4 findings
- Jun 27, 2011—2 findings
- Feb 3, 2011—7 findings · 1 harm
- Dec 7, 2010—3 findings
- Sep 15, 2010—6 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.
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction