Cycle 1
Health 2025-08-06 · Fire 2025-08-06
2 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Ashland, WI
Ashland Health Services
4-star overall rating with 4-star inspections with $19,988 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1319 Beaser Ave, Ashland, WI
(715) 682-3468
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1985-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
58 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.39
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.15
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.04
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.37
CMS adjusted RN staffing hours
Adjusted total hours
3.71
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,684
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
1.72
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0.52
Baseline 5.72% · Performance 7.68% · Measure score 0.52 · Achievement 0.52 · Improvement 0
Total nurse turnover
0
Baseline 54.76% · Performance 65.12% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.39 hours · Performance 2.84 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.16% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 6.52% · Lower 95% interval 5.77% |
| Discharge to community | 44.6% |
50.57%
6 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 40.48% · Lower 95% interval 31.56% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98% |
95.27%
2.7 pts better
|
Numerator 49 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 53.66% |
53.69%
About the same
|
Numerator 22 · Denominator 41 |
| Discharge mobility score | 46.34% |
50.94%
4.6 pts worse
|
Numerator 19 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 2% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 50 · Adjusted rate 2.31% |
| Healthcare-associated infections requiring hospitalization | 7.68% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 9.68% · Lower 95% interval 3.59% |
| Staff COVID-19 vaccination coverage | 12.82% |
8.2%
4.6 pts better
|
Numerator 5 · Denominator 39 |
| Staff flu vaccination coverage | 45% |
42%
3 pts better
|
Numerator 18 · Denominator 40 |
| Discharge function score | 58.54% |
56.45%
2.1 pts better
|
Numerator 24 · Denominator 41 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 30% |
25.2%
4.8 pts better
|
Numerator 9 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.6
1.1 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
95.7%
2 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 93.9% · Q3 97.0% · Q4 100.0% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
95.0%
2.2 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.2%
2.2 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 6.1% · Q3 3.0% · Q4 3.1% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
5.0%
0.2 pts worse
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 3.2% · Q3 3.4% · Q4 3.6% · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
4.9%
2.9 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 9.7% · Q3 0.0% · Q4 11.5% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.4% |
16.6%
7.8 pts worse
|
19.6%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 19.4% · Q3 30.0% · Q4 25.0% · 4Q avg 24.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.1% |
16.7%
4.4 pts worse
|
16.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 16.7% · Q3 26.9% · Q4 17.4% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 36.1% |
21.1%
15 pts worse
|
16.3%
19.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.3% |
17.3%
6 pts worse
|
14.9%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 20.0% · Q3 20.0% · Q4 33.3% · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.6% |
2.3%
1.3 pts worse
|
1.0%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.1% · Q4 7.1% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.0% |
3.0%
1 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 3.0% · Q3 0.0% · Q4 3.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.1% |
25.5%
4.6 pts worse
|
19.8%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 34.9% · Q3 32.7% · Q4 20.0% · 4Q avg 30.1% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
5.5%
4.3 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.5% |
86.8%
1.3 pts worse
|
81.7%
3.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 83.3% · Q4 82.6% · 4Q avg 85.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
15.0%
4 pts better
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 10.3% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
1.3%
1.6 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.1% |
82.2%
5.1 pts worse
|
79.7%
2.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.7% |
22.7%
7 pts better
|
23.9%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 13.8% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-05 · Fire 2024-06-05
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-06-28 · Fire 2023-06-28
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-06
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-09-06
E · Potential for more than minimal harm
2025-08-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-09-06
D · Potential for more than minimal harm
2025-08-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-09-06
C · Minimal harm
2025-08-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2024-06-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-05
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-07-10
C · Minimal harm
2024-06-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-10
E · Potential for more than minimal harm
2023-06-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-26
C · Minimal harm
2023-06-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-26
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-06
D · Potential for more than minimal harm
2025-08-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-06
F · Potential for more than minimal harm
2024-06-05
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-07-17
F · Potential for more than minimal harm
2024-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-17
F · Potential for more than minimal harm
2024-06-05
F887 · Infection Control Deficiencies
Health
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 2024-07-17
E · Potential for more than minimal harm
2024-06-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-05
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-17
C · Minimal harm
2024-06-05
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-07-17
G · Actual harm
2023-06-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-26
E · Potential for more than minimal harm
2023-06-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-28
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-28
F690 · Quality of Life and Care Deficiencies
Health
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 2023-07-26
D · Potential for more than minimal harm
2023-06-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-26
Penalties and ownership
What sits behind the stars
$19,988
2023-06-28
Fine
Fine · fine $19,988
Fine
Ownership
Baumann, Troy
5% Or Greater Direct Ownership Interest · Individual
Hoehn, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Mills, David
5% Or Greater Direct Ownership Interest · Individual
Baumann, Troy
Operational/Managerial Control · Individual
Baumann, Troy
Corporate Director · Individual
Hoehn, Jeffrey
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Corporate Director · Individual
Kurtz, Tammy
Operational/Managerial Control · Individual
Kurtz, Tammy
W-2 Managing Employee · Individual
Mills, David
Operational/Managerial Control · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Court Manor Health Services
Ashland, WI
3-star overall rating with 3-star inspections with $62,445 in total fines with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Northern Lights Hcc
Washburn, WI
3-star overall rating with 2-star inspections with $15,945 in total fines with 14 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Villa Maria Health And Rehab Ctr
Hurley, WI
2-star overall rating with 2-star inspections with abuse icon flag with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Jump out