Cycle 1
Health 2024-08-28 · Fire 2024-08-28
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Sheboygan, WI
Meadow View Health Services
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
3613 S 13th St, Sheboygan, WI
(920) 458-4040
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
32
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1996-12-01
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
1.05
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.78
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.53
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
2.99
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.57
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
1.21
CMS adjusted RN staffing hours
Adjusted total hours
4.05
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,027
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9909
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.21
Baseline 19.98% · Performance 19.02% · Measure score 5.21 · Achievement 5.21 · Improvement 2.77
Healthcare-associated infections
2.90
Performance 6.97% · Measure score 2.90 · Achievement 2.90 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.84
Baseline 44.44% · Performance 35.71% · Measure score 6.84 · Achievement 6.84 · Improvement 3.96
Adjusted total nurse staffing
0.13
Baseline 2.84 hours · Performance 3.02 hours · Measure score 0.13 · Achievement 0 · Improvement 0.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 14.04% · Lower 95% interval 7.75% |
| Discharge to community | 59.2% |
50.57%
8.6 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 50% · Lower 95% interval 46.26% |
| Medicare spending per beneficiary | 0.67 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 3.23% |
0.77%
2.5 pts worse
|
Numerator 1 · Denominator 31 |
| Discharge self-care score | 36.36% |
53.69%
17.3 pts worse
|
Numerator 8 · Denominator 22 |
| Discharge mobility score | 22.73% |
50.94%
28.2 pts worse
|
Numerator 5 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.97% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 6.45% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 8.11% |
8.2%
0.1 pts worse
|
Numerator 3 · Denominator 37 |
| Staff flu vaccination coverage | 22.22% |
42%
19.8 pts worse
|
Numerator 10 · Denominator 45 |
| Discharge function score | 40.91% |
56.45%
15.5 pts worse
|
Numerator 9 · Denominator 22 |
| 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 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · 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 | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.9 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.2
1.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.8 · 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 | 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 | 5.8% |
3.2%
2.6 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 7.1% · Q3 4.5% · Q4 4.5% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 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 who lose too much weight | 0.0% |
4.9%
4.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
16.6%
3 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 15.0% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.6% |
16.7%
11.9 pts worse
|
16.7%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · 4Q avg 28.6% · 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 | 16.2% |
21.1%
4.9 pts better
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.9% |
17.3%
1.6 pts worse
|
14.9%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · 4Q avg 18.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
2.3%
0.9 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 8.3% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
3.0%
1 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
25.5%
4.6 pts better
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 19.2% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.5%
2.2 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.6% · Q3 4.1% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.1% |
86.8%
1.7 pts worse
|
81.7%
3.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.7% · Q2 86.3% · Q3 85.2% · Q4 83.1% · 4Q avg 85.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.5% |
15.0%
1.5 pts worse
|
12.0%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 17.2% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.3%
0.4 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.4% |
82.2%
3.8 pts worse
|
79.7%
1.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.4% |
22.7%
6.3 pts better
|
23.9%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 17.2% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-19 · Fire 2023-07-19
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-07-20 · Fire 2022-07-20
9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-28
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-09-28
F · Potential for more than minimal harm
2024-08-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-28
F · Potential for more than minimal harm
2024-08-28
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Not marked corrected
F · Potential for more than minimal harm
2024-08-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-28
E · Potential for more than minimal harm
2024-08-28
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 2024-09-28
E · Potential for more than minimal harm
2024-08-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-28
D · Potential for more than minimal harm
2024-08-28
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 2024-09-10
E · Potential for more than minimal harm
2023-07-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-19
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-08-18
E · Potential for more than minimal harm
2022-07-20
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 2022-08-20
E · Potential for more than minimal harm
2022-07-20
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 2022-08-20
E · Potential for more than minimal harm
2022-07-20
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-08-20
D · Potential for more than minimal harm
2022-07-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-08-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-08-28
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 2024-09-28
E · Potential for more than minimal harm
2024-08-28
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-09-28
D · Potential for more than minimal harm
2024-08-28
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 2024-09-28
D · Potential for more than minimal harm
2024-08-28
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-09-28
D · Potential for more than minimal harm
2024-08-28
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 2024-09-28
G · Actual harm
2024-07-02
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 2024-07-24
D · Potential for more than minimal harm
2023-07-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-19
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 2023-08-18
D · Potential for more than minimal harm
2023-03-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-20
E · Potential for more than minimal harm
2022-07-20
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-08-20
D · Potential for more than minimal harm
2022-07-20
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2022-08-20
D · Potential for more than minimal harm
2022-07-20
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 2022-08-20
D · Potential for more than minimal harm
2022-07-20
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-08-20
D · Potential for more than minimal harm
2022-07-20
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 2022-08-20
D · Potential for more than minimal harm
2022-07-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-08-20
D · Potential for more than minimal harm
2022-07-20
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-08-20
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
Hoehn, Jeffrey
Corporate Director · Individual
Hoehn, Jeffrey
W-2 Managing Employee · Individual
Mills, David
5% Or Greater Indirect Ownership Interest · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Sheboygan Progressive Health Services
Sheboygan, WI
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Edenbrook Sheboygan
Sheboygan, WI
1-star overall rating with 1-star inspections with $202,946 in total fines with 12 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Sheboygan Health Services
Sheboygan, WI
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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