Cycle 1
Health 2025-05-07 · Fire 2025-05-07
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cornell, WI
Cornell Health Services
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
320 N 7th St, Cornell, WI
(715) 239-6288
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1997-09-01
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
0.84
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.58
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
0.90
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
764
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.11
Composite VBP score used to determine payment impact.
Payment multiplier
1.0187
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.37
Baseline 16.87% · Performance 17.09% · Measure score 9.37 · Achievement 9.37 · Improvement 0
Healthcare-associated infections
4.94
Baseline 6.53% · Performance 6.36% · Measure score 4.94 · Achievement 4.94 · Improvement 0.62
Total nurse turnover
9.31
Baseline 46.34% · Performance 25.64% · Measure score 9.31 · Achievement 9.31 · Improvement 9
Adjusted total nurse staffing
2.03
Baseline 3.35 hours · Performance 3.65 hours · Measure score 2.03 · Achievement 2.03 · Improvement 0.74
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.85% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 5.97% · Lower 95% interval 6.79% |
| Discharge to community | 54.56% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 51.56% · Lower 95% interval 44.47% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.08% |
95.27%
2.8 pts better
|
Numerator 51 · Denominator 52 |
| Falls with major injury | 1.92% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 52 |
| Discharge self-care score | 64.29% |
53.69%
10.6 pts better
|
Numerator 27 · Denominator 42 |
| Discharge mobility score | 73.81% |
50.94%
22.9 pts better
|
Numerator 31 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 52 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.36% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 2.22% · Lower 95% interval 3.44% |
| Staff COVID-19 vaccination coverage | 3.85% |
8.2%
4.3 pts worse
|
Numerator 2 · Denominator 52 |
| Staff flu vaccination coverage | 46.15% |
42%
4.1 pts better
|
Numerator 30 · Denominator 65 |
| Discharge function score | 73.81% |
56.45%
17.4 pts better
|
Numerator 31 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 36% |
25.2%
10.8 pts better
|
Numerator 9 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.6
0.8 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.2
0.1 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.4 · 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 97.0% · Q3 100.0% · Q4 94.1% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.2%
0.1 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 3.0% · Q3 0.0% · Q4 2.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
5.0%
3.4 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
4.9%
4.6 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 7.7% · Q3 7.4% · Q4 3.4% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.1% |
16.6%
2.5 pts worse
|
19.6%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 14.8% · Q3 20.0% · Q4 20.7% · 4Q avg 19.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.2% |
16.7%
13.5 pts better
|
16.7%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.3% · Q3 4.3% · Q4 0.0% · 4Q avg 3.2% · 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 | 23.1% |
21.1%
2 pts worse
|
16.3%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 41.5% · Q3 19.7% · Q4 7.8% · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.4% |
17.3%
2.1 pts worse
|
14.9%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 20.8% · Q3 24.1% · Q4 10.7% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
2.3%
1.2 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
3.0%
0.6 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.7% |
25.5%
1.2 pts worse
|
19.8%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.7% · Q2 20.2% · Q3 26.9% · Q4 26.3% · 4Q avg 26.7% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.5%
3.5 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.4% |
86.8%
2.4 pts worse
|
81.7%
2.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.2% · Q2 81.2% · Q3 86.8% · Q4 84.6% · 4Q avg 84.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.4% |
15.0%
8.6 pts better
|
12.0%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 6.1% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.0% |
82.2%
2.2 pts worse
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.8% |
22.7%
2.9 pts better
|
23.9%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 18.2% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-10 · Fire 2024-04-10
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-03-08 · Fire 2023-03-08
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-07
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-07
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-07
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 2025-05-30
F · Potential for more than minimal harm
2024-04-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-04-10
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-04-10
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 2024-05-09
F · Potential for more than minimal harm
2023-03-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-03-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-30
E · Potential for more than minimal harm
2024-09-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-04-10
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-09
Penalties and ownership
What sits behind the stars
Ownership
Nshf Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Baumann, Troy
5% Or Greater Indirect Ownership Interest · Individual
Hoehn, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Mills, David
5% Or Greater Indirect Ownership Interest · Individual
Baumann, Troy
Operational/Managerial Control · Individual
Baumann, Troy
Corporate Director · Individual
Belongia, Christina
Operational/Managerial Control · Individual
Cibc Bank Usa
5% Or Greater Security Interest · Organization
Cliftonlarsonallen Llp
Operational/Managerial Control · Organization
Continuum Therapy Partners
Operational/Managerial Control · Organization
Gee, Darren
Operational/Managerial Control · Individual
Greer, Lauren
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Corporate Director · Individual
Hostetler, Harry
Operational/Managerial Control · Individual
Mcconnell, Alexandria
Operational/Managerial Control · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
Nsh Rehab LLC
Operational/Managerial Control · Organization
Patzer, Colleen
Operational/Managerial Control · Individual
Purtell, Brian
Operational/Managerial Control · Individual
Wipfli Llp
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Meadowbrook At Bloomer
Bloomer, WI
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Dove Healthcare - Bloomer
Bloomer, WI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Dove Healthcare - Regional Vent Center
Chippewa Falls, WI
3-star overall rating with 3-star inspections with $66,888 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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