Cycle 1
Health 2024-09-25 · Fire 2024-09-25
13 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Shawano, WI
Birch Hill Health Services
2-star overall rating with 3-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1475 Birch Hill Lane, Shawano, WI
(715) 526-3161
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
43
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1988-06-01
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
0.52
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.39
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,642
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9963
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.68
Baseline 43.24% · Performance 36.36% · Measure score 6.68 · Achievement 6.68 · Improvement 3.24
Adjusted total nurse staffing
1.98
Baseline 4.06 hours · Performance 3.64 hours · Measure score 1.98 · Achievement 1.98 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.44% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 6.88% |
| Discharge to community | 41.03% |
50.57%
9.5 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 30.77% · Lower 95% interval 28.55% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 21 · Denominator 21 |
| Falls with major injury | 4.76% |
0.77%
4 pts worse
|
Numerator 1 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 9.52% |
2.29%
7.2 pts worse
|
Numerator 2 · Denominator 21 · Adjusted rate 8.36% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 20% |
8.2%
11.8 pts better
|
Numerator 8 · Denominator 40 |
| Staff flu vaccination coverage | 71.93% |
42%
29.9 pts better
|
Numerator 41 · Denominator 57 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
95.0%
0.1 pts worse
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.2%
0.7 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.3% · Q3 5.1% · Q4 0.0% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.9% |
5.0%
4.9 pts worse
|
11.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 17.1% · Q3 8.1% · Q4 11.1% · 4Q avg 9.9% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
4.9%
3.2 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 3.2% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
16.6%
1 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 12.9% · Q3 9.7% · Q4 20.7% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 44.9% |
16.7%
28.2 pts worse
|
16.7%
28.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.8% · Q2 46.2% · Q3 45.8% · Q4 41.7% · 4Q avg 44.9% · 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 | 20.8% |
21.1%
0.3 pts better
|
16.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.6% |
17.3%
14.3 pts worse
|
14.9%
16.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 27.6% · Q3 44.8% · Q4 32.1% · 4Q avg 31.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
2.3%
0.9 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 0.0% · Q3 2.9% · Q4 3.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
3.0%
1 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.7% · Q3 0.0% · Q4 2.7% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.9% |
25.5%
10.4 pts worse
|
19.8%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.0% · Q2 36.6% · Q3 31.3% · Q4 34.9% · 4Q avg 35.9% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
5.5%
1.7 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.6% · Q3 4.8% · Q4 3.4% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
86.8%
7.2 pts better
|
81.7%
12.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 90.0% · Q3 97.8% · Q4 93.6% · 4Q avg 94.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.1% |
82.2%
0.1 pts worse
|
79.7%
2.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-30 · Fire 2023-08-30
2 health deficiencies
Top issue: Infection Control (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2022-09-22 · Fire 2022-09-22
1 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-25
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 2024-10-25
F · Potential for more than minimal harm
2024-09-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-09-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-09-25
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-10-25
F · Potential for more than minimal harm
2023-08-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-30
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-30
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-30
E · Potential for more than minimal harm
2023-08-30
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 2023-09-30
E · Potential for more than minimal harm
2023-08-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-30
F · Potential for more than minimal harm
2022-09-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-12
E · Potential for more than minimal harm
2022-09-22
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 2022-10-12
E · Potential for more than minimal harm
2022-09-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-11-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-11-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-11-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-05-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-13
E · Potential for more than minimal harm
2024-09-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-09-25
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-09-25
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-09-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-09-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-09-25
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-09-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-25
F · Potential for more than minimal harm
2023-08-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-30
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-09-30
D · Potential for more than minimal harm
2022-09-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-12
Penalties and ownership
What sits behind the stars
Ownership
Nshr Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Arrowhead 123 LLC
5% Or Greater Indirect Ownership Interest · Organization
Baumann, Troy
5% Or Greater Indirect Ownership Interest · Individual
Baumann, Troy
Operational/Managerial Control · Individual
Baumann, Troy
Corporate Director · Individual
Hoehn, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Hoehn, Jeffrey
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Corporate Director · Individual
Mills, David
5% Or Greater Indirect Ownership Interest · Individual
Mills, David
Operational/Managerial Control · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
The Lane Morrell Bowen Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Evergreen Health Services
Shawano, WI
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Shawano Health Services
Shawano, WI
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
The Pines Post Acute And Memory Care
Clintonville, WI
3-star overall rating with 3-star inspections with $18,400 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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