Cycle 1
Health 2025-06-18 · Fire 2025-06-18
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Green Bay, WI
Green Bay Health Services
2-star overall rating with 3-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1640 Shawano Ave, Green Bay, WI
(920) 499-5177
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
125
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1983-12-01
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
0.91
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.73
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.37
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,165
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.49
Performance 20.74% · Measure score 1.49 · Achievement 1.49 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Baseline 6.21% · Performance 7.91% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.51
Baseline 67.50% · Performance 54.67% · Measure score 2.51 · Achievement 2.20 · Improvement 2.51
Adjusted total nurse staffing
1.45
Baseline 3.44 hours · Performance 3.49 hours · Measure score 1.45 · Achievement 1.45 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.31% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 11.86% · Lower 95% interval 7.1% |
| Discharge to community | 36.07% |
50.57%
14.5 pts worse
|
Worse than the National Rate · Eligible stays 45 · Observed rate 22.22% · Lower 95% interval 24.37% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 77.14% |
95.27%
18.1 pts worse
|
Numerator 27 · Denominator 35 |
| Falls with major injury | 5.71% |
0.77%
4.9 pts worse
|
Numerator 2 · Denominator 35 |
| Discharge self-care score | 41.67% |
53.69%
12 pts worse
|
Numerator 10 · Denominator 24 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 12 · Denominator 24 |
| 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 | 7.91% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 13.51% · Lower 95% interval 4.73% |
| Staff COVID-19 vaccination coverage | 5% |
8.2%
3.2 pts worse
|
Numerator 3 · Denominator 60 |
| Staff flu vaccination coverage | 34.43% |
42%
7.6 pts worse
|
Numerator 21 · Denominator 61 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 12 · Denominator 24 |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.6 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.2
About the same
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.7 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
95.7%
1.7 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 95.3% · Q3 98.1% · Q4 100.0% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
95.0%
3 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.2%
1.9 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.3% · Q3 7.5% · Q4 7.5% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.1% |
5.0%
5.1 pts worse
|
11.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 7.9% · Q3 12.2% · Q4 6.4% · 4Q avg 10.1% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
4.9%
1.3 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.6% · Q3 4.4% · Q4 2.2% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
16.6%
1.6 pts worse
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 12.8% · Q3 15.6% · Q4 21.7% · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.0% |
16.7%
13.3 pts worse
|
16.7%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 30.0% · Q3 31.4% · Q4 28.6% · 4Q avg 30.0% · 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 | 40.5% |
21.1%
19.4 pts worse
|
16.3%
24.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 40.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.2% |
17.3%
6.9 pts worse
|
14.9%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 33.3% · Q3 23.8% · Q4 7.1% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.5% |
2.3%
2.2 pts worse
|
1.0%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 4.0% · Q3 3.6% · Q4 4.3% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
3.0%
0.1 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.7% · Q3 1.9% · Q4 5.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.6% |
25.5%
2.1 pts worse
|
19.8%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.9% · Q2 24.5% · Q3 16.5% · Q4 29.1% · 4Q avg 27.6% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
5.5%
2.1 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 11.1% · Q3 4.0% · Q4 5.1% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.1% |
86.8%
2.7 pts worse
|
81.7%
2.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 79.0% · Q2 81.9% · Q3 92.4% · Q4 85.0% · 4Q avg 84.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
15.0%
2.5 pts better
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 15.8% · Expected 14.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
1.3%
2.4 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.1% · Q3 3.1% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.2% |
82.2%
8 pts worse
|
79.7%
5.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
22.7%
7.5 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 39.5% · Expected 31.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-30 · Fire 2024-05-30
13 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-04-12 · Fire 2023-04-12
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-18
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-06-26
E · Potential for more than minimal harm
2025-06-18
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 2025-06-23
E · Potential for more than minimal harm
2025-06-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-09
E · Potential for more than minimal harm
2025-06-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-08
E · Potential for more than minimal harm
2025-06-18
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2025-07-01
E · Potential for more than minimal harm
2025-06-18
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2025-07-07
F · Potential for more than minimal harm
2024-05-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-25
E · Potential for more than minimal harm
2024-05-30
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 2024-06-25
E · Potential for more than minimal harm
2024-05-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-27
E · Potential for more than minimal harm
2024-05-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-06-25
F · Potential for more than minimal harm
2023-04-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-13
E · Potential for more than minimal harm
2023-04-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-13
E · Potential for more than minimal harm
2023-04-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-13
E · Potential for more than minimal harm
2023-04-12
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-05-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-26
E · Potential for more than minimal harm
2025-06-18
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-07-14
E · Potential for more than minimal harm
2025-06-18
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 2025-07-14
E · Potential for more than minimal harm
2025-06-18
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-06-18
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-06-18
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 2025-07-14
D · Potential for more than minimal harm
2025-06-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-06-18
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 2025-07-14
D · Potential for more than minimal harm
2025-06-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-06-18
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-06-18
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 2025-07-14
D · Potential for more than minimal harm
2025-02-20
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-03-18
D · Potential for more than minimal harm
2025-02-20
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-03-18
D · Potential for more than minimal harm
2025-02-20
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 2025-03-18
D · Potential for more than minimal harm
2024-11-11
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-12-03
E · Potential for more than minimal harm
2024-05-30
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-25
E · Potential for more than minimal harm
2024-04-01
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 2024-04-22
D · Potential for more than minimal harm
2024-04-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-22
C · Minimal harm
2024-04-01
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2024-04-22
D · Potential for more than minimal harm
2023-04-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-12
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 2023-05-23
D · Potential for more than minimal harm
2023-04-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-12
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-05-23
Penalties and ownership
What sits behind the stars
Ownership
Nshc Wisconsin 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
Baumann, Troy
Operational/Managerial Control · Individual
Baumann, Troy
Corporate Director · Individual
Belongia, Christina
Operational/Managerial Control · Individual
Cibc Bank Usa
Operational/Managerial Control · Organization
Cibc Bank Usa
5% Or Greater Security Interest · Organization
Cibc Bank Usa
5% Or Greater Mortgage 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
Molski, Kristin
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
Ramnanan, Keshni
Operational/Managerial Control · Individual
Wipfli Llp
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Grancare Nursing Center
Green Bay, WI
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Woodside Lutheran Home
Green Bay, WI
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Odd Fellow Home
Green Bay, WI
2-star overall rating with 2-star inspections with $97,228 in total fines with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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