Cycle 1
Health 2025-03-26 · Fire 2025-03-26
11 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Marshfield, WI
North Shore Healthcare At Marshfield
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
814 W 14th St, Marshfield, WI
(715) 387-1188
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
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
1978-12-01
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
1.10
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.09
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.70
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
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,260
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.81
Baseline 20.11% · Performance 20.59% · Measure score 1.81 · Achievement 1.81 · Improvement 0
Healthcare-associated infections
0
Baseline 6.19% · Performance 7.82% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.48
Baseline 31.25% · Performance 29.03% · Measure score 8.48 · Achievement 8.48 · Improvement 2.97
Adjusted total nurse staffing
0.64
Baseline 3.09 hours · Performance 3.26 hours · Measure score 0.64 · Achievement 0.64 · Improvement 0.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.59% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 9.57% · Lower 95% interval 7.45% |
| Discharge to community | 56.56% |
50.57%
6 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 53.57% · Lower 95% interval 45.43% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.88% |
95.27%
1.6 pts better
|
Numerator 62 · Denominator 64 |
| Falls with major injury | 3.13% |
0.77%
2.4 pts worse
|
Numerator 2 · Denominator 64 |
| Discharge self-care score | 41.3% |
53.69%
12.4 pts worse
|
Numerator 19 · Denominator 46 |
| Discharge mobility score | 45.65% |
50.94%
5.3 pts worse
|
Numerator 21 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.56% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 64 · Adjusted rate 1.43% |
| Healthcare-associated infections requiring hospitalization | 7.82% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 9.09% · Lower 95% interval 4.11% |
| Staff COVID-19 vaccination coverage | 8.51% |
8.2%
0.3 pts better
|
Numerator 8 · Denominator 94 |
| Staff flu vaccination coverage | 33.07% |
42%
8.9 pts worse
|
Numerator 42 · Denominator 127 |
| Discharge function score | 58.7% |
56.45%
2.2 pts better
|
Numerator 27 · Denominator 46 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.14% |
96.28%
0.9 pts better
|
Numerator 34 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 46.15% |
25.2%
20.9 pts better
|
Numerator 12 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.7 |
1.6
2.1 pts worse
|
1.9
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 3.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
2.2
2 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
95.7%
2.2 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 91.1% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 80.4% |
95.0%
14.6 pts worse
|
95.5%
15.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 80.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.2%
3 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 3.9% · Q3 6.5% · Q4 6.7% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.5% |
5.0%
5.5 pts worse
|
11.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 9.8% · Q3 14.3% · Q4 5.1% · 4Q avg 10.5% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
4.9%
1.5 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.6% · Q3 0.0% · Q4 5.1% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.8% |
16.6%
4.2 pts worse
|
19.6%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 21.1% · Q3 24.3% · Q4 20.5% · 4Q avg 20.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.5% |
16.7%
9.2 pts better
|
16.7%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 9.4% · Q3 6.1% · Q4 5.9% · 4Q avg 7.5% · 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 | 25.7% |
21.1%
4.6 pts worse
|
16.3%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.3% |
17.3%
1 pts worse
|
14.9%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 15.8% · Q3 16.2% · Q4 21.1% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.3% |
2.3%
1 pts worse
|
1.0%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.7% · Q4 8.6% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.3% |
3.0%
2.3 pts worse
|
1.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 7.8% · Q3 2.3% · Q4 8.9% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.0% |
25.5%
10.5 pts worse
|
19.8%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.5% · Q2 25.1% · Q3 39.2% · Q4 40.1% · 4Q avg 36.0% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
5.5%
3 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 1.6% · Q4 3.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.7% |
86.8%
2.9 pts better
|
81.7%
8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 96.2% · Q3 90.5% · Q4 77.7% · 4Q avg 89.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
15.0%
7.1 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.3% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.3%
About the same
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.7% · Q3 0.0% · Q4 1.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.9% |
82.2%
6.7 pts better
|
79.7%
9.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.0% |
22.7%
5.3 pts worse
|
23.9%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.0% · Observed 23.6% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-04 · Fire 2024-01-04
5 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-11-10 · Fire 2022-11-10
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2024-01-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
D · Potential for more than minimal harm
2024-01-04
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-01-29
D · Potential for more than minimal harm
2024-01-04
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-01-29
E · Potential for more than minimal harm
2022-11-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-05
E · Potential for more than minimal harm
2022-11-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-12-05
Inspection history
Recent health citations
G · Actual harm
2025-07-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-07-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-07-07
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-03-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-26
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 2025-04-23
D · Potential for more than minimal harm
2025-03-26
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 2025-04-23
D · Potential for more than minimal harm
2025-03-26
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 2025-04-23
D · Potential for more than minimal harm
2025-03-26
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 2025-04-23
D · Potential for more than minimal harm
2024-01-04
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-01-31
D · Potential for more than minimal harm
2024-01-04
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 2024-01-29
D · Potential for more than minimal harm
2024-01-04
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-31
C · Minimal harm
2024-01-04
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 2024-01-29
C · Minimal harm
2024-01-04
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 2024-01-29
D · Potential for more than minimal harm
2022-11-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-12-05
D · Potential for more than minimal harm
2022-11-10
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 2022-12-05
Penalties and ownership
What sits behind the stars
Ownership
Nshr Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Arrowhead 123 LLC
5% Or Greater Indirect Ownership Interest · Organization
Baumann, Troy
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
Hellenbrand, Danielle
Operational/Managerial Control · Individual
Hoehn, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Hoehn, Jeffrey
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Corporate Director · Individual
Mills, David
5% Or Greater Indirect Ownership Interest · 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
The Lane Morrell Bowen Trust
5% Or Greater Indirect Ownership Interest · Organization
Wipfli Llp
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Norwood Health Ctr-Central
Marshfield, WI
5-star overall rating with 4-star inspections with 3 fire-safety deficiencies in the latest cycle
#2
Three Oaks Health Services
Marshfield, WI
2-star overall rating with 2-star inspections with $41,118 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Colonial Health Services
Colby, WI
2-star overall rating with 2-star inspections with $34,140 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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