Menomonee Falls Health Services

Penalties

• Aug 4, 2025 — Fine ($94,680)
• Nov 26, 2024 — Fine ($31,103)
• May 1, 2024 — Fine ($55,419)
• May 1, 2024 — Payment Denial · payment denial 8 days
• Dec 18, 2023 — Fine ($29,961)
• Dec 11, 2023 — Fine ($3,145)

Inspection findings

1. Dec 3, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Dec 8, 2025 · CMS health inspection

2. Aug 4, 2025 Fire Safety · 18 findings
   • Not serious Scope/severity F

     E0013 Emergency Preparedness Deficiencies

     Develop Emergency Preparedness policies and procedures.

     Corrected Aug 25, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Aug 26, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Aug 26, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Aug 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Aug 26, 2025 · CMS health inspection

   • Serious Scope/severity G

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Aug 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Aug 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0849 Administration Deficiencies

     Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

     Corrected Aug 26, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 3, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0887 Infection Control Deficiencies

     Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

     Corrected Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0947 Nursing and Physician Services Deficiencies

     Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

     Corrected Aug 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Aug 22, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Aug 22, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 22, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Aug 26, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Aug 25, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Aug 28, 2025 · CMS fire safety

3. Nov 26, 2024 Health · 5 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Dec 24, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Dec 24, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0685 Quality of Life and Care Deficiencies

     Assist a resident in gaining access to vision and hearing services.

     Corrected Dec 24, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Dec 24, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Dec 24, 2024 · CMS health inspection

4. May 1, 2024 Fire Safety · 36 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Jun 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Jun 6, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0582 Resident Rights Deficiencies

     Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0625 Resident Rights Deficiencies

     Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0678 Quality of Life and Care Deficiencies

     Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jun 6, 2024 · CMS health inspection

   • Serious Scope/severity G

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jun 6, 2024 · CMS health inspection

   • Serious Scope/severity G

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0699 Quality of Life and Care Deficiencies

     Provide care or services that was trauma informed and/or culturally competent.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0725 Nursing and Physician Services Deficiencies

     Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0811 Nutrition and Dietary Deficiencies

     Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0849 Administration Deficiencies

     Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Jun 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0271 Egress Deficiencies

     Have exits that are accessible at all times.

     Corrected Jun 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jun 9, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Jun 7, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jun 6, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jun 6, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Jun 6, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Jun 6, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Jun 6, 2024 · CMS fire safety

5. Dec 18, 2023 Health · 2 findings
   • Serious Scope/severity G Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jan 16, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0687 Quality of Life and Care Deficiencies

     Provide appropriate foot care.

     Corrected Jan 16, 2024 · CMS health inspection

6. Mar 23, 2023 Fire Safety · 10 findings
   • Not serious Scope/severity F

     E0037 Emergency Preparedness Deficiencies

     Establish staff and initial training requirements.

     Corrected Apr 28, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Apr 21, 2023 · CMS fire safety

   • Not serious Scope/severity D

     F0888 Infection Control Deficiencies

     Ensure staff are vaccinated for COVID-19

     Corrected Apr 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Apr 26, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Apr 25, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Apr 28, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Apr 28, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected Apr 21, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Apr 21, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Apr 28, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BAUMANN, TROY — adp of the snf, NOT APPLICABLE, since 10/01/2017
• BAUMANN, TROY — operational/managerial control, NOT APPLICABLE, since 10/01/2017
• BAUMANN, TROY — corporate director, NOT APPLICABLE, since 06/29/2017
• BELONGIA, CHRISTINA — operational/managerial control, NOT APPLICABLE, since 11/01/2019
• BELONGIA, CHRISTINA — adp of the snf, NOT APPLICABLE, since 11/01/2019
• GEE, DARREN — operational/managerial control, NOT APPLICABLE, since 11/30/2021
• GEE, DARREN — adp of the snf, NOT APPLICABLE, since 11/30/2021
• GREER, LAUREN — operational/managerial control, NOT APPLICABLE, since 11/29/2023
• GREER, LAUREN — adp of the snf, NOT APPLICABLE, since 11/29/2023
• GROSENICK, KARI — adp of the snf, NOT APPLICABLE, since 01/06/2025
• GROSENICK, KARI — operational/managerial control, NOT APPLICABLE, since 01/06/2025
• HOEHN, JEFFREY — corporate director, NOT APPLICABLE, since 06/29/2017
• HOEHN, JEFFREY — adp of the snf, NOT APPLICABLE, since 10/01/2017
• HOEHN, JEFFREY — operational/managerial control, NOT APPLICABLE, since 10/01/2017
• MILLS, DAVID — 5% or greater indirect ownership interest, 20%, since 06/29/2017
• PATZER, COLLEEN — operational/managerial control, NOT APPLICABLE, since 02/14/2023
• PATZER, COLLEEN — adp of the snf, NOT APPLICABLE, since 02/14/2023
• PURTELL, BRIAN — adp of the snf, NOT APPLICABLE, since 06/01/2018
• PURTELL, BRIAN — operational/managerial control, NOT APPLICABLE, since 06/01/2018
• RAMNANAN, KESHNI — adp of the snf, NOT APPLICABLE, since 01/01/2023
• CIBC BANK USA — 5% or greater security interest, NOT APPLICABLE, since 12/31/2024
• CIBC BANK USA — operational/managerial control, NOT APPLICABLE, since 12/31/2024
• CLIFTONLARSONALLEN LLP — operational/managerial control, NOT APPLICABLE, since 05/22/2018
• CLIFTONLARSONALLEN LLP — adp of the snf, NOT APPLICABLE, since 04/15/2025
• CONTINUUM THERAPY PARTNERS LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• CONTINUUM THERAPY PARTNERS LLC — adp of the snf, NOT APPLICABLE, since 04/15/2025
• MENOMONEE PROPERTY HOLDINGS, LLC — adp of the snf, NOT APPLICABLE, since 05/01/2022
• NORTH SHORE HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 10/01/2017
• NORTH SHORE HEALTHCARE LLC — adp of the snf, NOT APPLICABLE, since 04/15/2025
• NSH REHAB LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• NSH REHAB LLC — adp of the snf, NOT APPLICABLE, since 06/11/2025
• NSHF OPERATIONS LLC — 5% or greater direct ownership interest, 100%, since 07/24/2017
• NSHF WISCONSIN LLC — adp of the snf, NOT APPLICABLE, since 05/12/2025
• WIPFLI LLP — adp of the snf, NOT APPLICABLE, since 04/15/2025
• WIPFLI LLP — operational/managerial control, NOT APPLICABLE, since 02/01/2025