Cycle 1
Health 2025-05-28 · Fire 2025-05-28
2 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Ashland, WI
Court Manor Health Services
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
911 3rd St West, Ashland, WI
(715) 682-8172
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
50
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1983-03-01
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
1.03
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.16
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
1.62
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.05
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,916
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9912
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.60
Performance 19.30% · Measure score 4.60 · Achievement 4.60 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.56
Performance 6.77% · Measure score 3.56 · Achievement 3.56 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.09
Baseline 41.46% · Performance 38.78% · Measure score 6.09 · Achievement 6.09 · Improvement 1.12
Adjusted total nurse staffing
0.99
Baseline 3.34 hours · Performance 3.36 hours · Measure score 0.99 · Achievement 0.99 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.24% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 3.7% · Lower 95% interval 5.97% |
| Discharge to community | 49.83% |
50.57%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 50% · Lower 95% interval 34.78% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 94.29% |
95.27%
1 pts worse
|
Numerator 33 · Denominator 35 |
| Falls with major injury | 5.71% |
0.77%
4.9 pts worse
|
Numerator 2 · Denominator 35 |
| Discharge self-care score | 27.59% |
53.69%
26.1 pts worse
|
Numerator 8 · Denominator 29 |
| Discharge mobility score | 34.48% |
50.94%
16.5 pts worse
|
Numerator 10 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 35 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.77% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 3.45% · Lower 95% interval 4.07% |
| Staff COVID-19 vaccination coverage | 24.19% |
8.2%
16 pts better
|
Numerator 15 · Denominator 62 |
| Staff flu vaccination coverage | 42.42% |
42%
0.4 pts better
|
Numerator 28 · Denominator 66 |
| Discharge function score | 37.93% |
56.45%
18.5 pts worse
|
Numerator 11 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · 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 | 61.9% |
25.2%
36.7 pts better
|
Numerator 13 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
2.2
1.3 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.0 · Expected 1.4 · Used in QM five-star |
| 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 | 97.8% |
95.0%
2.8 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.2%
2.4 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 7.1% · Q3 4.3% · Q4 6.5% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 48.9% |
5.0%
43.9 pts worse
|
11.4%
37.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 57.1% · Q2 50.0% · Q3 47.8% · Q4 41.3% · 4Q avg 48.9% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
4.9%
1.9 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 10.0% · Q3 4.9% · Q4 4.9% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.0% |
16.6%
5.4 pts worse
|
19.6%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 21.4% · Q3 28.9% · Q4 25.0% · 4Q avg 22.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.3% |
16.7%
11.6 pts worse
|
16.7%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 30.0% · Q3 33.3% · Q4 21.1% · 4Q avg 28.3% · 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 | 27.3% |
21.1%
6.2 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 28.3% · Q3 39.9% · Q4 10.1% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.9% |
17.3%
15.6 pts worse
|
14.9%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 43.9% · Q3 30.0% · Q4 22.5% · 4Q avg 32.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
2.3%
0.6 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.7% · Q3 4.1% · Q4 1.9% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
3.0%
2.4 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.9% |
25.5%
3.4 pts worse
|
19.8%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 20.9% · Q3 40.3% · Q4 24.3% · 4Q avg 28.9% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.5%
3.4 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 2.6% · Q4 2.6% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
86.8%
5.5 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 92.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.1% |
15.0%
9.1 pts worse
|
12.0%
12.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 19.0% · Expected 8.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 12.0% |
1.3%
10.7 pts worse
|
1.6%
10.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 12.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
82.2%
12.8 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.3% |
22.7%
4.4 pts better
|
23.9%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 14.3% · Expected 18.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-11 · Fire 2024-04-11
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-03-22 · Fire 2023-03-22
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-18
F · Potential for more than minimal harm
2025-05-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-18
E · Potential for more than minimal harm
2025-05-28
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 2025-06-18
D · Potential for more than minimal harm
2025-05-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-05-28
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-05-28
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-06-18
E · Potential for more than minimal harm
2024-04-11
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-04-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-17
F · Potential for more than minimal harm
2023-03-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-19
F · Potential for more than minimal harm
2023-03-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-22
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-04-19
Inspection history
Recent health citations
J · Immediate jeopardy
2025-05-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-24
D · Potential for more than minimal harm
2023-03-22
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 2023-04-19
Penalties and ownership
What sits behind the stars
$62,445
2025-05-28
Fine
Fine · fine $62,445
Fine
$0
2025-05-28
Payment Denial
Payment Denial · denial start 2025-06-24 · 1 days
1 day denial
Ownership
North Shore Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Baumann, Troy
5% Or Greater Direct Ownership Interest · Individual
Baumann, Troy
Operational/Managerial Control · Individual
Baumann, Troy
Corporate Officer · Individual
Hoehn, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Hoehn, Jeffrey
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Corporate Officer · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
Nshc Wisconsin LLC
5% Or Greater Direct Ownership Interest · Organization
Nshc Wisconsin LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Ashland Health Services
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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
#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
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