LANCASTER HEALTH SERVICES

1350 S MADISON ST
LANCASTER, WI, 53813
6087234143
CCN: 525352
2
Overall
2
Health
4
Staffing
2
Quality
ChainNORTH SHORE HEALTHCARE
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
NSHR OPERATIONS LLC5% OR GREATER DIRECT OWNERSHIP INTEREST100%
ARROWHEAD 123 LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
THE LANE MORRELL BOWEN TRUST5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
BAUMANN, TROY5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
HOEHN, JEFFREY5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
MILLS, DAVID5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
HOEHN, JEFFREYCORPORATE DIRECTORNOT APPLICABLE
BAUMANN, TROYCORPORATE DIRECTORNOT APPLICABLE
HOEHN, JEFFREYOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
MILLS, DAVIDOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
NORTH SHORE HEALTHCARE LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
BAUMANN, TROYOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (1)
DateTypeAmount
2025-08-19Fine$22K
Health Deficiencies (18)
2025-08-19 · Health
D
F881 · Infection Control Deficiencies
Implement a program that monitors antibiotic use.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F804 · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
D
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
J
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
D
F578 · Resident Rights Deficiencies
Honor 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.
2025-02-19 · Health
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2024-08-27 · Health
D
F697 · Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
2024-07-24 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F851 · Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
D
F757 · Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
2024-04-24 · Health
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2023-04-06 · Health
C
F888 · Infection Control Deficiencies
Ensure staff are vaccinated for COVID-19
D
F883 · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.80
3.68
RN Hrs/Resident/Day
0.70
0.54
LPN Hrs/Resident/Day
0.79
0.81
CNA Hrs/Resident/Day
2.31
2.33
PT Hrs/Resident/Day
0.01
0.12
Data as of 2026-03-01