Willowcrest Health Services
South Milwaukee, Wisconsin · CCN 525413
26 surveys since 2010. The first finding at harm level was recorded in 2014.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 127
- Surveys
- 26
- Harm or worse
- 5
- Immediate jeopardy
- 3
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
- 100
- Ownership
- For profit - Limited Liability company
- Chain
- NORTH SHORE HEALTHCARE
- County
- Milwaukee
- Medicare-certified since
- 1988
CMS ratings
- Overall
- 2
- Health inspection
- 2
- Staffing
- 2
- Quality measures
- 4
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 39 for-profit facilities of 100–127 beds in Wisconsin.
Last survey on record
Jun 5, 2025
522 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 | 3.57 | 3.64 |
| Registered-nurse hours per resident day | 0.62 | — |
| Annual nurse turnover | 41.3% | 50.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $21,285 across 1 penalty
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 | J25.6% | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D2261.1% | E513.9% | F513.9% |
| No harm, potential for minimal | A— | B12.8% | C12.8% |
Most frequently cited here
In CMS’s current monthly file.
- F6843×
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.
- F6902×
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- F6932×
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
- F6952×
Provide safe and appropriate respiratory care for a resident when needed.
In the surveyor’s words
From the most serious findings on record at Willowcrest Health Services, in the surveyor’s own words.
- Immediate jeopardy, isolatedF678Mar 29, 2024
Based on interview and record review the Facility did not ensure 1 (R127) of 1 Residents who did not have fully signed DNR (do not resuscitate) documents was provided with CPR (Cardiopulmonary Resuscitation). R127 returned from the hospital on [DATE]. Upon return there is a verbal consent obtained on [DATE] from the POA (power of attorney)/daughter on the (CPR) Cardiopulmonary resuscitation consent form & Emergency Care Do Not Resuscitate Order (DNR). Facility staff did not follow up on having R127's POA/daughter sign these forms and the physician did not sign the Emergency Care Do Not Resuscitate Order (DNR). The Facility therefore did not have a valid DNR order. On [DATE] R127 experienced a choking episode, became unresponsive was not breathing & pulseless. […]
- Immediate jeopardy, isolatedF689Mar 29, 2024
Based on interview and record review the Facility did not ensure each Resident received adequate supervision and assistance devices to prevent accidents for 3 (R127, R63, & R45) of 8 Residents. R127 was readmitted to the facility on [DATE]. The hospital discharge summary for a discharge date of [DATE], under discharge recommendations documents 5. Diet: Diabetic (carb controlled) diet, low sodium; add protein supplements with meals (sugar free gelatin and low carb Glucerna). Per Speech Therapy: 1) Cont (continue) general solids, thin liquids; constant supervision/assist for all intake. 2) Meds (medication) whole in puree or with sips of liquid (minimum of 3 oz (ounce) liquid wash following same). […]
- No harm, potential for more than minimal, widespreadF851Jun 5, 2025
Based upon interview and record review, the facility did not ensure the mandatory staffing data, submitted for the first quarter of 2025 (October 1- December 31), was accurate. During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered for excessively low weekend staffing. This had the potential to affect all 67 residents. Findings include: Review of the facility PBJ data, as part of the survey offsite process, indicates during the first quarter of the federal fiscal year 2025 (October 1- December 31) the facility was triggered for excessively low weekend staffing. Based on the Facility Assessment, the Facility is licensed for 100 residents. Maximum residents per unit is 44 residents each on North and East units. […]
- No harm, potential for more than minimal, widespreadF880Jun 5, 2025
Based on Observation, Interview and Record Review, the facility could not provide adequate proof of implementing an effective water management plan. This deficient practice had the ability to affect 67 of 67 residents residing at the facility at the time of this recertification survey. *The facility could not provide documentation of weekly temperature testing or weekly flushing logs for the vacant south unit (rooms 101-123). Findings include: Surveyor reviewed the Facility's Water Management Program Policy with a implementation date of 7/16/2022. […]
- No harm, potential for more than minimal, widespreadF812Mar 29, 2024
Based on observation and interview the facility did not follow professional standards for food service safety to ensure dishes and utensils were properly handled properly after sanitization from the dishwasher. This had the potential to affect all 78 residents if they receive food from the kitchen. *Dietary staff were observed going from the dirty side of the dishwashing machine to the clean side without performing hand hygiene. Findings include: On 03/25/24 at 10:00 AM, Surveyor observed Dietary Aide (DA)-E at the dishwashing station. DA-E was rinsing dishes on the right side of the dishwasher and placing them in a tray. DA-E then opened the dishwasher and removed a tray of clean dishes and slid the tray down the counter. […]
Read 23 findings in full →The most serious and the most recent: 23 of 127 on record.
Every survey on record
FindingsAt actual harm or above
- Jun 5, 2025Standard13 findings
- Mar 5, 2025Complaint1 finding
- Oct 14, 2024Complaint1 finding
- Mar 29, 2024Standard and complaint21 findings · 2 harm
- Jan 12, 2023Standard and complaint4 findings
- Nov 4, 2021Standard5 findings
- Apr 28, 2021Complaint1 finding
- Sep 29, 2020Complaint3 findings
Show the 18 earlier surveys
- Jul 20, 2020Infection control1 finding
- Jun 16, 2020Infection control1 finding
- Feb 27, 2020Complaint3 findings
- Oct 30, 2019Standard and complaint6 findings · 1 harm
- Jul 23, 2018Standard4 findings
- Apr 12, 2018Complaint1 finding
- May 15, 2017Standard and complaint9 findings
- Feb 1, 2017Complaint3 findings
- Mar 21, 2016Standard and complaint10 findings · 1 harm
- Aug 19, 2015Complaint7 findings
- Apr 6, 2015Standard and complaint10 findings
- Sep 2, 2014Complaint3 findings
- May 19, 2014Complaint5 findings · 1 harm
- Jan 9, 2014—5 findings
- Oct 4, 2012—1 finding
- Mar 27, 2012—2 findings
- Sep 6, 2011—5 findings
- Sep 2, 2010—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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