Cycle 1
Health 2025-02-05 · Fire 2025-02-05
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Hammond, WI
Hammond Health Services
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
425 Davis St, Hammond, WI
(715) 796-2218
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
33
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1992-12-01
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
1.21
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.46
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.88
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
1.13
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,775
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0089
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
8.33
Baseline 45.45% · Performance 29.63% · Measure score 8.33 · Achievement 8.33 · Improvement 7.18
Adjusted total nurse staffing
2.48
Baseline 3.69 hours · Performance 3.78 hours · Measure score 2.48 · Achievement 2.48 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.83% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 5.93% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 22 · Denominator 22 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 22 |
| 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 | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 22 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 59 |
| Staff flu vaccination coverage | 63.77% |
42%
21.8 pts better
|
Numerator 44 · Denominator 69 |
| 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 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · 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 | 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 | 5.3% |
3.2%
2.1 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 0.0% · Q3 7.7% · Q4 6.7% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
5.0%
0.8 pts better
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.1% · Q3 0.0% · Q4 7.7% · 4Q avg 4.2% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
4.9%
1.8 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.7% |
16.6%
7.9 pts better
|
19.6%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 5.0% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
16.7%
5.8 pts better
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.9% · 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 | 37.2% |
21.1%
16.1 pts worse
|
16.3%
20.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 37.2% · 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 · 4Q avg 31.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
3.0%
0.7 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 7.7% · Q3 0.0% · Q4 3.4% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.9% |
25.5%
6.6 pts better
|
19.8%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 15.2% · Q3 10.9% · Q4 18.8% · 4Q avg 18.9% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
5.5%
2.3 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.2% · Q3 3.0% · Q4 3.7% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
86.8%
9 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.3% · Q2 96.9% · Q3 96.6% · Q4 100.0% · 4Q avg 95.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
1.3%
2.5 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 8.7% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
82.2%
14.7 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-31 · Fire 2024-01-31
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-01-05 · Fire 2023-01-05
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-05
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-02-28
C · Minimal harm
2025-02-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-28
F · Potential for more than minimal harm
2024-01-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-31
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-03-01
F · Potential for more than minimal harm
2023-01-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-30
F · Potential for more than minimal harm
2023-01-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-01-05
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 2023-01-30
D · Potential for more than minimal harm
2023-01-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-30
C · Minimal harm
2023-01-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-05
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2025-03-03
F · Potential for more than minimal harm
2024-01-31
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 2024-03-01
D · Potential for more than minimal harm
2024-01-31
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-03-01
B · Minimal harm
2023-01-05
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-01-30
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
Operational/Managerial Control · Organization
Cibc Bank Usa
5% Or Greater Security Interest · Organization
Cliftonlarsonallen Llp
Operational/Managerial Control · Organization
Continuum Therapy Partners
Operational/Managerial Control · Organization
Edelman, Laurie
Operational/Managerial Control · Individual
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
Wipfli Llp
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Baldwin Care Center
Baldwin, WI
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Park View Home
Woodville, WI
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Deerfield Care Center, LLC
New Richmond, WI
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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