Elroy Health Services
307 Royall Ave, Elroy, WI 53929
Elroy Health Services is a nursing home in Elroy, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (608) 462-8491
- Last standard health inspection
- May 20, 2026 (5 months ago)
- Certified beds
- 80
- Residents per day, on average
- 60
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Nsh Elroy LLC
- Chain
- North Shore Healthcare
- Takes part in
- Medicare and Medicaid
More health citations than the Wisconsin average (40 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
2 citations
Health inspection on August 26, 2026
CMS lists this as a complaint inspection.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on September 21, 2026.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on September 21, 2026.
CMS has cited this home for F0554 2 times since 2024.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
6 citations
Health inspection on May 20, 2026
CMS lists this as a standard inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
39 of 323 Wisconsin homes (12%) got a citation at the immediate jeopardy level in 2026.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 16, 2026.
CMS has cited this home for F0689 4 times since 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on June 16, 2026.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on June 16, 2026.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on June 16, 2026.
CMS has cited this home for F0677 2 times since 2024.
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on June 16, 2026.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on June 16, 2026.
9 citations
Fire safety inspection on May 20, 2026
CMS lists this as a standard inspection.
Citation K0223. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on June 15, 2026.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 15, 2026.
CMS has cited this home for K0353 3 times since 2024.
Citation K0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on June 15, 2026.
Citation K0911. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on June 15, 2026.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on June 15, 2026.
CMS has cited this home for K0920 2 times since 2024.
Citation K0345. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on June 15, 2026.
Citation K0351. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on June 15, 2026.
Citation K0521. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on June 15, 2026.
CMS has cited this home for K0521 2 times since 2024.
Citation K0927. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
CMS lists it as corrected on June 15, 2026.
CMS has cited this home for K0927 2 times since 2024.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
3 citations
Health inspection on July 1, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
77 of 323 Wisconsin homes (24%) got a citation at the actual harm level in 2025.
Citation F0684. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 29, 2025.
CMS has cited this home for F0684 2 times since 2024.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 29, 2025.
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on July 29, 2025.
Fine
July 1, 2025 (1 year ago)
CMS fine of $33,320 on July 1, 2025.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
12 citations
Health inspection on March 3, 2025
CMS lists this as a standard inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0686. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 1, 2025.
CMS has cited this home for F0686 2 times since 2024.
Citation F0725. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on April 1, 2025.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 1, 2025.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 1, 2025.
CMS has cited this home for F0880 2 times since 2023.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 1, 2025.
CMS has cited this home for F0584 3 times since 2023.
Citation F0679. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on April 1, 2025.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on April 1, 2025.
CMS has cited this home for F0550 3 times since 2024.
Citation F0561. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on April 1, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on April 1, 2025.
CMS has cited this home for F0609 2 times since 2024.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on April 1, 2025.
CMS has cited this home for F0610 2 times since 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 1, 2025.
Citation F0744. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on April 1, 2025.
5 citations
Fire safety inspection on March 3, 2025
CMS lists this as a standard inspection.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 27, 2025.
Citation K0227. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
CMS lists it as corrected on March 27, 2025.
Citation K0341. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on March 27, 2025.
Citation K0281. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install proper backup exit lighting.
CMS lists it as corrected on March 27, 2025.
Citation K0325. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed hallway dispensers for alcohol-based hand rub.
CMS lists it as corrected on March 27, 2025.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
4 citations
Health inspection on November 9, 2024
CMS lists this as a complaint inspection.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on December 6, 2024.
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on December 6, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 6, 2024.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on December 6, 2024.
6 citations
Health inspection on July 30, 2024
CMS lists this as a complaint inspection.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on August 21, 2024.
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on August 21, 2024.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on August 21, 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on August 21, 2024.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on August 21, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 21, 2024.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
5 citations
Health inspection on February 6, 2024
CMS lists this as a standard inspection.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on February 26, 2024.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 26, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on February 26, 2024.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on February 24, 2024.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on February 24, 2024.
12 citations
Fire safety inspection on February 6, 2024
CMS lists this as a standard inspection.
Citation E0013. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop Emergency Preparedness policies and procedures.
CMS lists it as corrected on March 15, 2024.
Citation K0741. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on March 15, 2024.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 15, 2024.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 15, 2024.
Citation K0362. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on March 15, 2024.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on March 15, 2024.
Citation K0712. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on March 15, 2024.
Citation K0918. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on March 15, 2024.
Citation K0521. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on March 15, 2024.
Citation K0912. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on March 15, 2024.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on March 15, 2024.
Citation K0927. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
CMS lists it as corrected on March 15, 2024.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
2 citations
Health inspection on December 13, 2023
CMS lists this as a complaint inspection.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 5, 2024.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 5, 2024.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CIBC BANK USAOperational/managerial control · not applicable · since 12/31/2024
- CLIFTONLARSONALLENOperational/managerial control · not applicable · since 05/22/2018
- CONTINUUM THERAPY PARTNERS LLCOperational/managerial control · not applicable · since 03/01/2025
- NORTH SHORE HEALTHCARE LLCOperational/managerial control · not applicable · since 02/01/2018
- NSH REHAB LLCOperational/managerial control · not applicable · since 03/01/2025
- WIPFLI LLPOperational/managerial control · not applicable · since 02/01/2025
- BAUMANN, TROYOperational/managerial control · not applicable · since 12/19/2017
- BELONGIA, CHRISTINAOperational/managerial control · not applicable · since 11/01/2019
- GEE, DARRENOperational/managerial control · not applicable · since 11/30/2021
- GREEN, TONYOperational/managerial control · not applicable · since 07/25/2026
- GREER, LAURENOperational/managerial control · not applicable · since 11/29/2023
- HOEHN, JEFFREYOperational/managerial control · not applicable · since 12/19/2017
- OROURKE, KATHERINEOperational/managerial control · not applicable · since 02/01/2023
- PATZER, COLLEENOperational/managerial control · not applicable · since 02/14/2023
- PURTELL, BRIANOperational/managerial control · not applicable · since 06/01/2018
Questions
When was Elroy Health Services last inspected?
CMS lists May 20, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Elroy Health Services have?
CMS lists 40 health citations since December 13, 2023. CMS also calls these deficiencies.
Has Elroy Health Services been fined?
CMS lists 1 fine in the past three years, $33,320 in total.
What is the CMS star rating of Elroy Health Services?
Its CMS overall star rating is 1 of 5.
Is Elroy Health Services a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.