Staffing
CMS publishes a 4-star staffing rating for this facility.
RN staffing was 1.52 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceAsk Trust Hub Network
CMS overview
No proprietary TrustHub score. These ratings are published separately by CMS.
Facility information
CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.
Decision guide
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
CMS publishes a 4-star staffing rating for this facility.
RN staffing was 1.52 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceThe latest standard inspection on Mar 26, 2025 cited 3 deficiencies.
View inspection evidenceCMS-published records list 15 ownership or control parties.
CMS records show an ownership change effective October 2017.
View ownership evidenceCMS groups this facility with a chain covering 59 facilities across 4 states or territories.
View chain evidenceCMS records show a $120,900 fine in the loaded enforcement dataset.
View enforcement evidence →Ownership & operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
SeniorTrustHub found evidence connecting this facility to:
20 currently connected nursing homes share this CMS organization identity with NSHF OPERATIONS LLC.
These figures summarize currently connected CMS-certified nursing homes. Some facilities have incomplete measures; missing values are omitted, not treated as zero. Ownership structures can change. State operator or licensee evidence may differ from CMS ownership disclosures.
Ownership
These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jul 24, 2017
Other facilities connected through this exact CMS organization identity: 0 across WI.
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 20%
Association date reported to CMS: Jun 29, 2017
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 29, 2017
Individual · CORPORATE DIRECTOR
Association date reported to CMS: Jun 29, 2017
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Oct 1, 2017
Other facilities connected through this exact CMS organization identity: 0 across WI.
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Jun 29, 2017
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jul 24, 2017
Other facilities connected through this exact CMS organization identity: 19 across WI.
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 40%
Association date reported to CMS: Jun 29, 2017
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 40%
Association date reported to CMS: Jun 29, 2017
Individual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 20%
Association date reported to CMS: Jun 29, 2017
Individual · CORPORATE DIRECTOR
Published ownership percentage: 100%
Association date reported to CMS: Jun 29, 2017
Individual · CORPORATE DIRECTOR
Published ownership percentage: 100%
Association date reported to CMS: Jun 29, 2017
Organization · OPERATIONAL/MANAGERIAL CONTROL
Published ownership percentage: 100%
Association date reported to CMS: Oct 1, 2017
Other facilities connected through this exact CMS organization identity: 54 across MI, MN, WI.
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Jun 29, 2017
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 0 across WI.
Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.
Chain context
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 377 is a grouping identifier, not a legal organization.
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 59 | 2.7 | 3.4 |
| Mon Jun | 59 | 2.7 | 3.5 |
| Fri May | 59 | 2.7 | 3.5 |
| Wed Apr | 59 | 2.7 | 3.5 |
| Sun Mar | 58 | 2.8 | 3.5 |
| Sun Feb | 58 | 2.8 | 3.5 |
Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.
View official CMS sourceInspections & deficiencies
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 29, 2025)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 29, 2025)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Jul 29, 2025)
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 29, 2025)
No health-deficiency rows were deterministically linked to this inspection.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 14, 2025)
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Apr 14, 2025)
Provide and implement an infection prevention and control program.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 14, 2025)
No health-deficiency rows were deterministically linked to this inspection.
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.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 8, 2024)
Ensure that residents are free from significant medication errors.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 8, 2024)
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 8, 2024)
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 9, 2023)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 9, 2023)
Provide and implement an infection prevention and control program.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 9, 2023)
No health-deficiency rows were deterministically linked to this inspection.
Give residents a notice of rights, rules, services and charges.
CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Nov 11, 2022)
Provide activities to meet all resident's needs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 11, 2022)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 11, 2022)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 11, 2022)
Provide safe and appropriate respiratory care for a resident when needed.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 11, 2022)
Penalties & enforcement
Published fine amount: $120,900.00
Questions to ask
Facility history
8 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
RN staffing increased from 1.43 to 1.61 hours per resident day between 2025Q2 and 2025Q3. Staffing improved across those reported periods.
1.43 → 1.61
CMS · Reported in a source release · View related evidence
CMS recorded a $120,900 civil monetary penalty.
CMS · Recorded event date · View related evidence
4 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
5 deficiencies were recorded.
CMS · Recorded event date · View related evidence
An ownership change was recorded. New organization: NSH LAKE MILLS LLC.
FMG MULBERRY STREET WISCONSIN LLC → NSH LAKE MILLS LLC
CMS · Recorded event date · View related evidence
Staffing
CMS staffing rating: 4 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.635 | 3.316 |
| RN categories | 1.594 | 1.353 |
Contract staff accounted for 0% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.027 lower than the prior loaded quarter.
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 3.618 | 1.427 | 0.362 | 1.829 | 7.1% | 91 |
| 2025Q3 | 3.609 | 1.611 | 0.223 | 1.774 | 3.7% | 92 |
| 2025Q4 | 3.52 | 1.552 | 0.164 | 1.804 | 0.9% | 92 |
| 2026Q1 | 3.543 | 1.525 | 0.167 | 1.852 | 0% | 90 |
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
Planned evidence layers
These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.
Trust participation
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