Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Heritage Health Services

Port Washington, WI · 50 certified beds · Last Life Safety survey March 12, 2025

CMS Certification Number 525586 · first certified June 1996

Ownership

Operated by NORTH SHORE HEALTHCARE · For profit - Limited Liability company

Ownership changed October 1, 2017 (change of ownership)from FMG NORTH WISCONSIN STREET WISCONSIN LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within WI

41 citations — more than 98% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 12 citations; the earlier surveys in the window averaged 14.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (April 2026 to June 2026), and past the point by which nine in ten WI facilities have been surveyed. This facility’s last Life Safety survey was March 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

6 of the 41 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 41 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.
F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	41
Median facility in WI	17
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
January 26, 2023	10
February 6, 2024	19
March 12, 2025	12

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0712	Have simulated fire drills held at unexpected times.	3	2025-03-12
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	3	2025-03-12
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	2	2025-03-12
K-0341	Install a fire alarm system that can be heard throughout the facility.	2	2025-03-12
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2025-03-12
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	2	2025-03-12
K-0919	Meet requirements for the use of electrical equipment.	2	2024-02-06
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2024-02-06

What the citations cover

Citations by CMS category

Smoke Deficiencies 14
Gas, Vacuum, and Electrical Systems Deficiencies 8
Emergency Preparedness Deficiencies 6
Egress Deficiencies 5
Other 8

Citations by CMS category
Category	Citations
Smoke Deficiencies	14
Gas, Vacuum, and Electrical Systems Deficiencies	8
Emergency Preparedness Deficiencies	6
Egress Deficiencies	5
Services Deficiencies	3
Miscellaneous Deficiencies	3
Construction Deficiencies	2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

March 12, 2025 — 12 citations

Citations issued on March 12, 2025
Tag	What the surveyor checks	Status
E-0020	Establish policies and procedures including evacuation.	Deficient, Provider has date of correction (April 11, 2025)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (April 11, 2025)
K-0133	Install a two-hour-resistant firewall separation.	Deficient, Provider has date of correction (April 11, 2025)
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (April 11, 2025)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (April 11, 2025)
K-0311	Have an enclosure around a vertical opening shaft.	Deficient, Provider has date of correction (April 11, 2025)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (April 11, 2025)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (April 11, 2025)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (April 11, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (April 11, 2025)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (April 30, 2025)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (April 11, 2025)

February 6, 2024 — 19 citations

Citations issued on February 6, 2024
Tag	What the surveyor checks	Status
E-0013	Develop Emergency Preparedness policies and procedures.	Deficient, Provider has date of correction (March 4, 2024)
E-0025	Create arrangements with other facilities to receive patients.	Deficient, Provider has date of correction (March 4, 2024)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (March 4, 2024)
K-0271	Have exits that are accessible at all times.	Deficient, Provider has date of correction (March 4, 2024)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (March 4, 2024)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (March 4, 2024)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (March 4, 2024)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (March 4, 2024)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (March 4, 2024)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (March 4, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (March 4, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (March 4, 2024)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (March 4, 2024)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (March 4, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (March 4, 2024)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (March 4, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (March 4, 2024)
K-0919	Meet requirements for the use of electrical equipment.	Deficient, Provider has date of correction (March 4, 2024)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (March 4, 2024)

January 26, 2023 — 10 citations

Citations issued on January 26, 2023
Tag	What the surveyor checks	Status
E-0006	Conduct risk assessment and an All-Hazards approach.	Deficient, Provider has date of correction (March 10, 2023)
K-0222	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.	Deficient, Provider has date of correction (March 10, 2023)
K-0281	Install proper backup exit lighting.	Deficient, Provider has date of correction (March 10, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (March 10, 2023)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (March 10, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (March 10, 2023)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (March 10, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (March 10, 2023)
K-0919	Meet requirements for the use of electrical equipment.	Deficient, Provider has date of correction (March 10, 2023)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (March 10, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.