WILLOWCREST HEALTH SERVICES
3821 S CHICAGO AVE, SOUTH MILWAUKEE, WI 53172 · CCN 525413
Ratings
- Overall
- ★★☆☆☆ 2
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★★★★ 5
- Staffing
- ★☆☆☆☆ 1
Facility
- Ownership type
- For profit - Limited Liability company
- Certified beds
- 100
- Avg residents/day
- 74.6
- Phone
- 4147627336
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 | 2025-06-05 | 14 | 9.8 | 9.5 | +4.2 worse |
| 2 | 2024-03-29 | 18 | 9.2 | 9.8 | +8.8 worse |
| 3 | 2023-01-12 | 4 | 8.3 | 9.3 | -4.3 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 1 |
| Quality of life and care | 7 |
| Resident rights | 1 |
| Pharmacy service | 3 |
| Administration | 1 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.40 | 54.9% |
| RN staffing (reported) | 0.53 | 66.7% |
| Total nurse staffing (adjusted) | 3.22 | — |
Fines & penalties
- Total fines
- $21,285
- 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 (36)2 immediate jeopardy
- DF0605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.2025-06-05 · Health · corrected 2025-07-05
Potential for more than minimal harm
- DF0628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.2025-06-05 · Health · corrected 2025-07-05
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-06-05 · Health · corrected 2025-07-05
Potential for more than minimal harm
- DF0688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.2025-06-05 · Health · corrected 2025-07-05
Potential for more than minimal harm
- DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2025-06-05 · Health · corrected 2025-07-05
Potential for more than minimal harm
- DF0693Ensure 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.2025-06-05 · Health · corrected 2025-07-05
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2025-06-05 · Health · corrected 2025-07-05
Potential for more than minimal harm
- DF0699Provide care or services that was trauma informed and/or culturally competent.2025-06-05 · Health · corrected 2025-07-05
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-06-05 · Health · corrected 2025-07-05
Potential for more than minimal harm
- DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2025-06-05 · Health · corrected 2025-07-05
Potential for more than minimal harm
- DF0760Ensure that residents are free from significant medication errors.2025-06-05 · Health · corrected 2025-07-05
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.2025-06-05 · Health · corrected 2025-07-05
Potential for more than minimal harm
- FF0880Provide and implement an infection prevention and control program.2025-06-05 · Health · corrected 2025-07-05
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-03-05 · Health · corrected 2025-03-31
Potential for more than minimal harm
- CF0732Post nurse staffing information every day.2024-10-14 · Health · corrected 2024-11-12
Potential for minimal harm
- BF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2024-03-29 · Health · corrected 2024-04-26
Potential for minimal harm
- JF0678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.2024-03-29 · Health · corrected 2024-04-26
Immediate jeopardy
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-03-29 · Health · corrected 2024-04-26
Potential for more than minimal harm
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-03-29 · Health · corrected 2024-04-26
Immediate jeopardy
- DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2024-03-29 · Health · corrected 2024-04-26
Potential for more than minimal harm
- DF0692Provide enough food/fluids to maintain a resident's health.2024-03-29 · Health · corrected 2024-04-26
Potential for more than minimal harm
- DF0693Ensure 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.2024-03-29 · Health · corrected 2024-04-26
Potential for more than minimal harm
- DF0694Provide for the safe, appropriate administration of IV fluids for a resident when needed.2024-03-29 · Health · corrected 2024-04-26
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2024-03-29 · Health · corrected 2024-04-26
Potential for more than minimal harm
- EF0730Observe each nurse aide's job performance and give regular training.2024-03-29 · Health · corrected 2024-04-26
Potential for more than minimal harm
- DF0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.2024-03-29 · Health · corrected 2024-04-26
Potential for more than minimal harm
- DF0761Ensure 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.2024-03-29 · Health · corrected 2024-04-26
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.2024-03-29 · Health · corrected 2024-04-26
Potential for more than minimal harm
- FF0880Provide and implement an infection prevention and control program.2024-03-29 · Health · corrected 2024-04-26
Potential for more than minimal harm
- EF0944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.2024-03-29 · Health · corrected 2024-04-26
Potential for more than minimal harm
- EF0946Provide training in compliance and ethics.2024-03-29 · Health · corrected 2024-04-26
Potential for more than minimal harm
- EF0949Provide behavior health training consistent with the requirements and as determined by a facility assessment.2024-03-29 · Health · corrected 2024-04-26
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-01-12 · Health · corrected 2023-02-10
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-01-12 · Health · corrected 2023-02-10
Potential for more than minimal harm
- EF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2023-01-12 · Health · corrected 2023-02-10
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.2023-01-12 · Health · corrected 2023-02-10
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| NSHF OPERATIONS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2017-07-24 |
| BAUMANN, TROY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 40% | 2017-06-29 |
| HOEHN, JEFFREY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 40% | 2017-06-29 |
| MILLS, DAVID | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 20% | 2017-06-29 |
| NORTH SHORE HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2017-10-01 |
| BAUMANN, TROY | Individual | CORPORATE DIRECTOR | — | 2017-06-29 |
| HOEHN, JEFFREY | Individual | CORPORATE DIRECTOR | — | 2017-06-29 |
| HOEHN, JEFFREY | Individual | W-2 MANAGING EMPLOYEE | — | 2017-06-29 |
Other facilities in SOUTH MILWAUKEE
| Name | Overall | Beds |
|---|---|---|
| CHI FRANCISCAN VILLA | ★☆☆☆☆ | 90 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.