LANCASTER HEALTH SERVICES
1350 S MADISON ST, LANCASTER, WI 53813 · CCN 525352
Ratings
- Overall
- ★★☆☆☆ 2
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★☆☆☆ 2
- Staffing
- ★★★★☆ 4
Facility
- Ownership type
- For profit - Limited Liability company
- Certified beds
- 50
- Avg residents/day
- 39.0
- Phone
- 6087234143
Inspection history vs Wisconsin & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Wisconsin avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-08-19 | 7 | 9.8 | 9.5 | -2.8 better |
| 2 | 2024-07-24 | 7 | 9.2 | 9.8 | -2.2 better |
| 3 | 2023-04-06 | 4 | 8.3 | 9.3 | -4.3 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 1 |
| Resident assessment and care planning | 1 |
| Resident rights | 1 |
| Nutrition and dietary | 2 |
| Pharmacy service | 1 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.80 | 37.3% |
| RN staffing (reported) | 0.70 | 33.3% |
| Total nurse staffing (adjusted) | 3.84 | — |
Fines & penalties
- Total fines
- $21,645
- Number of fines
- 1
- Number of penalties
- 1
- Payment denials
- 0
Chain
- Chain
- NORTH SHORE HEALTHCARE
- Facilities in chain
- 58
- Chain avg overall
- 2.80 / 5
Inspection citations (18)1 immediate jeopardy
- DF0578Honor 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.2025-08-19 · Health · corrected 2025-09-16
Potential for more than minimal harm
- JF0605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.2025-08-19 · Health · corrected 2025-09-16
Immediate jeopardy
- DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2025-08-19 · Health · corrected 2025-09-16
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2025-08-19 · Health · corrected 2025-09-16
Potential for more than minimal harm
- EF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2025-08-19 · Health · corrected 2025-09-16
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-08-19 · Health · corrected 2025-09-16
Potential for more than minimal harm
- DF0881Implement a program that monitors antibiotic use.2025-08-19 · Health · corrected 2025-09-16
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-02-19 · Health · corrected 2025-03-18
Potential for more than minimal harm
- DF0610Respond appropriately to all alleged violations.2025-02-19 · Health · corrected 2025-03-18
Potential for more than minimal harm
- DF0697Provide safe, appropriate pain management for a resident who requires such services.2024-08-27 · Health · corrected 2024-09-27
Potential for more than minimal harm
- DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2024-07-24 · Health · corrected 2024-08-23
Potential for more than minimal harm
- FF0851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.2024-07-24 · Health · corrected 2024-03-05
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2024-07-24 · Health · corrected 2024-08-23
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-04-24 · Health · corrected 2024-05-03
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-04-06 · Health · corrected 2023-05-02
Potential for more than minimal harm
- FF0880Provide and implement an infection prevention and control program.2023-04-06 · Health · corrected 2023-05-02
Potential for more than minimal harm
- DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2023-04-06 · Health · corrected 2023-05-02
Potential for more than minimal harm
- CF0888Ensure staff are vaccinated for COVID-192023-04-06 · Health · corrected 2023-04-06
Potential for minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| NSHR OPERATIONS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2019-10-01 |
| ARROWHEAD 123 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2019-10-01 |
| THE LANE MORRELL BOWEN TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2019-10-01 |
| BAUMANN, TROY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2019-10-01 |
| HOEHN, JEFFREY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2019-10-01 |
| MILLS, DAVID | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2019-10-01 |
| NORTH SHORE HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2019-12-01 |
| BAUMANN, TROY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2019-10-01 |
| HOEHN, JEFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2019-10-01 |
| MILLS, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2019-10-01 |
| BAUMANN, TROY | Individual | CORPORATE DIRECTOR | — | 2019-10-01 |
| HOEHN, JEFFREY | Individual | CORPORATE DIRECTOR | — | 2019-10-01 |
Other facilities in LANCASTER
| Name | Overall | Beds |
|---|---|---|
| ORCHARD MANOR | ★★★★★ | 74 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.