SNF
WILLOWCREST HEALTH SERVICES
CCN: 525413 · SOUTH MILWAUKEE, WI 53172 · Milwaukee County
Overview
- Address
- 3821 S CHICAGO AVE, SOUTH MILWAUKEE, WI 53172
- Phone
- 4147627336
- Certified beds
- 100
- Avg daily residents
- 75 (75% of beds filled)
- Ownership
- For-profit LLC
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 1988-07-21
- Setting
- Urban
2 /5
★★★★★
CMS Overall Rating
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 3.40 | 4.07 | 3.22 | ≥ 3.48 | Below floor |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 0.53 | 0.71 | 0.50 | ≥ 0.55 | Below floor |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 0.97 | 0.90 | 0.92 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 1.90 | 2.46 | 1.80 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 1.50 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.05 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Total nurse (weekend)
3.00
hrs / resident / day
RN (weekend)
0.32
hrs / resident / day
Total nurse (adjusted, weekend)
2.84
hrs / resident / day
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Total nursing staff turnover
54.9%
annual
RN turnover
66.7%
annual
Administrators departed
1
last 12 months
Resident acuity
Nursing Case-Mix Index
1.44
higher acuity than avg
Case-Mix Index Ratio
1.05
facility / state ratio
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2025-06-05 | 14 | 13 | 1 | 80 | 1 | 80 |
| Cycle 2/3 (prior) | 2024-03-29 | 18 | 17 | 4 | 246 | 1 | 246 |
Total weighted health score
121.5
lower is better
Deficiencies (36)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
2 A/B/C No actual harm — minor
32 D/E/F Actual harm — potential for minor
2 J/K/L Immediate jeopardy
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D | 2025-06-05 | 2025-07-05 |
| 0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D | 2025-06-05 | 2025-07-05 |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | 2025-06-05 | 2025-07-05 |
| 0688 | Provide 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. | D | 2025-06-05 | 2025-07-05 |
| 0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | 2025-06-05 | 2025-07-05 |
| 0693 | 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. | D | 2025-06-05 | 2025-07-05 |
| 0695 | Provide safe and appropriate respiratory care for a resident when needed. | D | 2025-06-05 | 2025-07-05 |
| 0699 | Provide care or services that was trauma informed and/or culturally competent. | D | 2025-06-05 | 2025-07-05 |
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | 2025-06-05 | 2025-07-05 |
| 0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | 2025-06-05 | 2025-07-05 |
| 0760 | Ensure that residents are free from significant medication errors. | D | 2025-06-05 | 2025-07-05 |
| 0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F | 2025-06-05 | 2025-07-05 |
| 0880 | Provide and implement an infection prevention and control program. | F | 2025-06-05 | 2025-07-05 |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | 2025-03-05 | 2025-03-31 |
| 0732 | Post nurse staffing information every day. | C | 2024-10-14 | 2024-11-12 |
| 0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | B | 2024-03-29 | 2024-04-26 |
| 0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | 2024-03-29 | 2024-04-26 |
| 0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | 2024-03-29 | 2024-04-26 |
| 0692 | Provide enough food/fluids to maintain a resident's health. | D | 2024-03-29 | 2024-04-26 |
| 0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | D | 2024-03-29 | 2024-04-26 |
| 0695 | Provide safe and appropriate respiratory care for a resident when needed. | D | 2024-03-29 | 2024-04-26 |
| 0730 | Observe each nurse aide's job performance and give regular training. | E | 2024-03-29 | 2024-04-26 |
| 0758 | Implement 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. | D | 2024-03-29 | 2024-04-26 |
| 0761 | Ensure 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. | D | 2024-03-29 | 2024-04-26 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | 2024-03-29 | 2024-04-26 |
| 0880 | Provide and implement an infection prevention and control program. | F | 2024-03-29 | 2024-04-26 |
| 0944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | E | 2024-03-29 | 2024-04-26 |
| 0946 | Provide training in compliance and ethics. | E | 2024-03-29 | 2024-04-26 |
| 0949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. | E | 2024-03-29 | 2024-04-26 |
| 0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | J | 2024-03-29 | 2024-04-26 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | 2024-03-29 | 2024-04-26 |
| 0693 | 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. | D | 2024-03-29 | 2024-04-26 |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | 2023-01-12 | 2023-02-10 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | 2023-01-12 | 2023-02-10 |
| 0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | 2023-01-12 | 2023-02-10 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | 2023-01-12 | 2023-02-10 |
Penalties (1)
Fines issued
1
last 3 years
Total fines
$21,285
| Date | Type | Fine amount |
|---|---|---|
| 2024-03-29 | Fine | $21,285 |
Source: CMS Nursing Home Penalties.
Financial Health (FY 2023)
Payer mix (share of resident days)
Medicare 7.4% Medicaid 35.1% Other 57.5%
Operating performance
Operating Margin
8.8%
Total Margin
9.2%
Occupancy Rate
57.9%
Cost per Resident Day
$46
Revenue & costs
Net Patient Revenue
$10.5M
Total Costs
$1.3M
Net Income
$977K
Balance sheet
Total Assets
$5.5M
Total Liabilities
$7.9M
Fund Balance
-$2.4M
Current Ratio
0.38
Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.
Ownership & Corporate Structure
Chain: NORTH SHORE HEALTHCARE
- Chain ID
377- Facilities in chain
- 58
- Legal business name
- NSH SOUTH MILWAUKEE LLC
Chain-average star ratings (for peer context)
Overall
2.8
Health
2.8
Staffing
3.5
QM
2.6
Owner / manager organizations (2)
| Organization | Role | Association |
|---|---|---|
| NSHF OPERATIONS LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 07/24/2017 |
| NORTH SHORE HEALTHCARE LLC | OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2017 |
Owner / manager individuals (6)
| Name | Role | Association |
|---|---|---|
| BAUMANN, TROY | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 06/29/2017 |
| HOEHN, JEFFREY | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 06/29/2017 |
| MILLS, DAVID | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 06/29/2017 |
| BAUMANN, TROY | CORPORATE DIRECTOR | since 06/29/2017 |
| HOEHN, JEFFREY | CORPORATE DIRECTOR | since 06/29/2017 |
| HOEHN, JEFFREY | W-2 MANAGING EMPLOYEE | since 06/29/2017 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- No
- Hospital-based
- No
- Resident / family council
- Resident
- Sprinkler systems
- Yes
- Abuse citation flag
- No
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Penalties (
nh-penalties), vintage 2026, downloaded 2026-04-14 , 16,915 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows. - Skilled Nursing Facility Cost Report (
snf-cost-report), vintage 2023, downloaded 2026-04-14 , 14,120 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 113 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Cost Report | Cost per Resident Day ($) | $46 | metrics.cost_per_resident_day |
| Cost Report | Current Ratio | 0.38 | metrics.current_ratio |
| Cost Report | fiscal_year | 2,023 | fiscal_year |
| Cost Report | Medicaid Day Share (%) | 35.1% | metrics.medicaid_day_share |
| Cost Report | Medicare Day Share (%) | 7.4% | metrics.medicare_day_share |
| Cost Report | Net Income ($) | $976,682 | metrics.net_income |
| Cost Report | Net Patient Revenue ($) | $10,533,259 | metrics.net_patient_revenue |
| Cost Report | Occupancy Rate (%) | 57.9% | metrics.occupancy_rate |
| Cost Report | Operating Margin (%) | 8.8% | metrics.operating_margin |
| Cost Report | Total Assets ($) | $5,510,421 | metrics.total_assets |
| Cost Report | Total Costs ($) | $1,305,831 | metrics.total_costs |
| Cost Report | Total Fund Balances ($) | $-2,391,418 | metrics.fund_balance |
| Cost Report | Total Liabilities ($) | $7,901,839 | metrics.total_liabilities |
| Cost Report | Total Margin (%) | 9.2% | metrics.total_margin |
| Provider Information | Abuse Icon | N | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 0.92279 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 1.79760 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 0.49903 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 3.21942 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 2.84311 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 74.6 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.90433 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.45776 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.71281 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 4.07490 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 3.59159 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | 2.8 | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | 2.8 | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | 2.6 | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | 3.5 | Chain Average Staffing Rating |
| Provider Information | Chain ID | 377 | Chain ID |
| Provider Information | Chain Name | NORTH SHORE HEALTHCARE | Chain Name |
| Provider Information | City/Town | SOUTH MILWAUKEE | City/Town |
| Provider Information | CMS Certification Number (CCN) | 525413 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | N | Continuing Care Retirement Community |
| Provider Information | County/Parish | Milwaukee | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 1988-07-21 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 2 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 42.8943 | Latitude |
| Provider Information | Legal Business Name | NSH SOUTH MILWAUKEE LLC | Legal Business Name |
| Provider Information | Location | 3821 S CHICAGO AVE,SOUTH MILWAUKEE,WI,53172 | Location |
| Provider Information | Long-Stay QM Rating | 4 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -87.864 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 1 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 100 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | — | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | 58 | Number of Facilities in Chain |
| Provider Information | Number of Fines | 1 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.44355 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 1.04784 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 2 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | For profit - Limited Liability company | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 3821 S CHICAGO AVE | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | WILLOWCREST HEALTH SERVICES | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 390 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 5 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 80 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 1 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 13 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2025-06-05 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 80 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 14 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 17 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2024-03-29 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 246 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 4 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 246 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 18 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.32300 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 66.7 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 1.50062 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 0.97394 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 1.89722 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.05230 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 0.52669 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 3.39784 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | 5 | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | — | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 1 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | WI | State |
| Provider Information | Telephone Number | 4147627336 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 21285.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 3.00067 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 1 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 54.9 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 121.500 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | Resident | With a Resident and Family Council |
| Provider Information | ZIP Code | 53172 | ZIP Code |