Cycle 1
Health 2024-09-11 · Fire 2024-09-11
11 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Two Rivers, WI
Hamilton Health Services
2-star overall rating with 3-star inspections with 9 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
1 Hamilton Dr, Two Rivers, WI
(920) 793-2261
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
21
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
2001-11-12
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
1.30
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.45
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.36
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.95
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.27
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,780
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
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
0.69
Baseline 73.33% · Performance 67.57% · Measure score 0.69 · Achievement 0 · Improvement 0.69
Adjusted total nurse staffing
1.42
Baseline 3.16 hours · Performance 3.48 hours · Measure score 1.42 · Achievement 1.42 · Improvement 0.72
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.14% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 12.9% · Lower 95% interval 7.11% |
| Discharge to community | 49.24% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 43.33% · Lower 95% interval 33.36% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2% |
8.2%
6.2 pts worse
|
Numerator 1 · Denominator 50 |
| Staff flu vaccination coverage | 16.13% |
42%
25.9 pts worse
|
Numerator 15 · Denominator 93 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · 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 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · 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 | 94.4% |
95.7%
1.3 pts worse
|
93.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.0% · 4Q avg 94.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.0% |
95.0%
14 pts worse
|
95.5%
14.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 81.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.2%
0.4 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.0% |
5.0%
About the same
|
11.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.0% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
4.9%
About the same
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.4% |
16.6%
7.2 pts better
|
19.6%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.4% |
16.7%
6.7 pts worse
|
16.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.4% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.1% |
17.3%
1.2 pts better
|
14.9%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 7.1% |
2.3%
4.8 pts worse
|
1.0%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.2% |
3.0%
4.2 pts worse
|
1.7%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.0% |
25.5%
5.5 pts worse
|
19.8%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.0% |
| Percentage of long-stay residents with pressure ulcers | 12.1% |
5.5%
6.6 pts worse
|
5.1%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.6% |
86.8%
21.2 pts worse
|
81.7%
16.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 73.5% · Q2 70.0% · Q4 52.0% · 4Q avg 65.6% |
| 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.6% |
82.2%
34.6 pts worse
|
79.7%
32.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-12 · Fire 2023-07-12
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-06-15 · Fire 2022-06-15
10 health deficiencies
Top issue: Administration (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-09-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-09-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-11
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 2024-09-25
E · Potential for more than minimal harm
2024-09-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-02
D · Potential for more than minimal harm
2024-09-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-13
F · Potential for more than minimal harm
2023-07-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-01
F · Potential for more than minimal harm
2023-07-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-07-12
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 2023-08-07
E · Potential for more than minimal harm
2023-07-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-07-12
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 2023-07-19
F · Potential for more than minimal harm
2022-06-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-06-16
F · Potential for more than minimal harm
2022-06-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-06-16
E · Potential for more than minimal harm
2022-06-15
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 2022-09-30
E · Potential for more than minimal harm
2022-06-15
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 2022-06-16
E · Potential for more than minimal harm
2022-06-15
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-07-06
E · Potential for more than minimal harm
2022-06-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-16
E · Potential for more than minimal harm
2022-06-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-28
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Not marked corrected
E · Potential for more than minimal harm
2024-09-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-11
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 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
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 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-11
G · Actual harm
2024-07-08
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 2024-07-29
D · Potential for more than minimal harm
2024-07-08
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 2024-07-29
D · Potential for more than minimal harm
2024-07-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-29
D · Potential for more than minimal harm
2024-07-08
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-07-29
D · Potential for more than minimal harm
2024-02-20
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-03-18
F · Potential for more than minimal harm
2023-07-12
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 2023-08-07
F · Potential for more than minimal harm
2023-07-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-12
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 2023-08-07
D · Potential for more than minimal harm
2023-07-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-07
F · Potential for more than minimal harm
2022-06-15
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 2022-06-29
E · Potential for more than minimal harm
2022-06-15
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-06-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-06-15
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 2022-07-06
D · Potential for more than minimal harm
2022-06-15
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-15
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 2022-07-15
D · Potential for more than minimal harm
2022-06-15
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 2022-07-06
D · Potential for more than minimal harm
2022-06-15
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 2022-07-15
Penalties and ownership
What sits behind the stars
Ownership
Nshr 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
The Lane Morrell Bowen Trust
5% Or Greater Indirect Ownership Interest · Organization
Arrowhead 123 LLC
5% Or Greater Indirect Ownership Interest · Organization
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
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
Sumner, Colin
Operational/Managerial Control · Individual
Wipfli Llp
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
North Ridge Health and Rehabilitation Center
Manitowoc, WI
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Shady Lane Nursing Care Center
Manitowoc, WI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
St Marys Home for the Aged
Manitowoc, WI
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out