Cycle 1
Health 2024-12-18 · Fire 2024-12-18
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Altoona, WI
Oakwood Health Services
2-star overall rating with 2-star inspections with $36,552 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2512 New Pine Dr, Altoona, WI
(715) 833-0400
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1990-01-01
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
1.13
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.71
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.30
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.75
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
1.12
CMS adjusted RN staffing hours
Adjusted total hours
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
61%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,477
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.09
Baseline 18.35% · Performance 20.93% · Measure score 1.09 · Achievement 1.09 · Improvement 0
Healthcare-associated infections
0
Baseline 5.84% · Performance 9.10% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.24
Baseline 56.60% · Performance 38.18% · Measure score 6.24 · Achievement 6.24 · Improvement 5.30
Adjusted total nurse staffing
2.09
Baseline 3.19 hours · Performance 3.67 hours · Measure score 2.09 · Achievement 2.09 · Improvement 1.37
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.64% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 134 · Observed rate 6.72% · Lower 95% interval 6.11% |
| Discharge to community | 53.79% |
50.57%
3.2 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 45.31% · Lower 95% interval 45.31% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 54.55% |
95.27%
40.7 pts worse
|
Numerator 36 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 37.14% |
53.69%
16.5 pts worse
|
Numerator 13 · Denominator 35 |
| Discharge mobility score | 45.71% |
50.94%
5.2 pts worse
|
Numerator 16 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 66 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.09% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 13.64% · Lower 95% interval 5.3% |
| Staff COVID-19 vaccination coverage | 2.38% |
8.2%
5.8 pts worse
|
Numerator 2 · Denominator 84 |
| Staff flu vaccination coverage | 44.92% |
42%
2.9 pts better
|
Numerator 53 · Denominator 118 |
| Discharge function score | 68.57% |
56.45%
12.1 pts better
|
Numerator 24 · Denominator 35 |
| Transfer of health information to provider | 52.38% |
95.95%
43.6 pts worse
|
Numerator 11 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · 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 | 1.8 |
1.6
0.2 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.2 · Expected 2.3 · 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 2.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.3% |
95.7%
5.4 pts worse
|
93.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.5% · Q2 94.4% · Q3 94.1% · Q4 91.2% · 4Q avg 90.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
95.0%
0.2 pts better
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.2%
0.3 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 2.9% · Q4 8.8% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.1% |
5.0%
9.1 pts worse
|
11.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 11.8% · Q3 12.5% · Q4 19.4% · 4Q avg 14.1% |
| 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 · Q1 0.0% · Q2 3.7% · Q4 10.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.0% |
16.6%
6.4 pts worse
|
19.6%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 21.4% · Q4 25.0% · 4Q avg 23.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.7% |
16.7%
5 pts better
|
16.7%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 10.0% · 4Q avg 11.7% · 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 | 36.0% |
21.1%
14.9 pts worse
|
16.3%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
17.3%
3.1 pts worse
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 20.0% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.0% |
2.3%
1.7 pts worse
|
1.0%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 3.5% · Q3 3.3% · Q4 2.5% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
3.0%
0.5 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.7% · Q3 2.9% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.1% |
25.5%
9.6 pts worse
|
19.8%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 29.2% · Q3 47.0% · Q4 35.4% · 4Q avg 35.1% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
5.5%
3.9 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 4.3% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.5% |
86.8%
22.3 pts worse
|
81.7%
17.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 82.1% · Q2 69.1% · Q3 53.4% · Q4 59.0% · 4Q avg 64.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 34.7% |
15.0%
19.7 pts worse
|
12.0%
22.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.7% · Observed 36.1% · Expected 11.6% · Used in QM five-star |
| 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% · Q2 0.0% · Q3 0.0% · Q4 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 | 66.1% |
82.2%
16.1 pts worse
|
79.7%
13.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.9% |
22.7%
0.2 pts worse
|
23.9%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 25.0% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-25 · Fire 2023-10-25
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-10-05 · Fire 2022-10-05
8 health deficiencies
Top issue: Infection Control (4 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-12-18
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-12-18
D · Potential for more than minimal harm
2023-10-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-30
C · Minimal harm
2023-10-25
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 2023-11-30
F · Potential for more than minimal harm
2022-10-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-10-24
F · Potential for more than minimal harm
2022-10-05
K233 · Egress Deficiencies
Fire Safety
Install resident room doors of proper design and width.
Corrected 2022-11-04
F · Potential for more than minimal harm
2022-10-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-11-04
E · Potential for more than minimal harm
2022-10-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-04
E · Potential for more than minimal harm
2022-10-05
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-11-04
E · Potential for more than minimal harm
2022-10-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-10-05
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-10-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-10-27
C · Minimal harm
2022-10-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-11-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-03
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 2025-06-18
J · Immediate jeopardy
2025-02-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-03
F · Potential for more than minimal harm
2024-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-18
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 2025-01-15
D · Potential for more than minimal harm
2024-12-18
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-18
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 2025-01-15
J · Immediate jeopardy
2024-08-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-19
D · Potential for more than minimal harm
2024-08-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-19
F · Potential for more than minimal harm
2024-07-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-12
F · Potential for more than minimal harm
2023-10-25
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 2023-11-16
E · Potential for more than minimal harm
2023-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-25
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 2023-11-16
D · Potential for more than minimal harm
2023-08-10
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 2023-09-09
E · Potential for more than minimal harm
2023-03-15
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-15
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-15
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 2023-04-13
D · Potential for more than minimal harm
2023-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-13
E · Potential for more than minimal harm
2022-10-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-10-05
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 2022-11-04
D · Potential for more than minimal harm
2022-10-05
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 2022-11-04
Penalties and ownership
What sits behind the stars
$22,925
2025-02-20
Fine
Fine · fine $22,925
Fine
$13,627
2024-08-26
Fine
Fine · fine $13,627
Fine
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
Corporate Director · Individual
Baumann, Troy
W-2 Managing Employee · Individual
Hoehn, Jeffrey
Corporate Director · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
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