Cycle 1
Health 2024-12-18 · Fire 2024-12-18
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Randolph, WI
Randolph Health Services
1-star overall rating with 1-star inspections with $76,264 in total fines with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
502 S High St, Randolph, WI
(920) 326-3171
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
84
Certified beds
Average residents
60
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1984-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.06
Registered nurse staffing
LPN hours / resident day
0.24
Licensed practical nurse staffing
Aide hours / resident day
2.29
Nurse aide staffing
Weekend hours
3.16
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.6
0.5 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.2
0.4 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
95.7%
1.1 pts better
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.6% |
95.0%
0.4 pts worse
|
95.5%
0.9 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.2%
1.6 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
5.0%
2.6 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.5% |
4.9%
0.6 pts worse
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
16.6%
6.2 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 18.7% |
16.7%
2 pts worse
|
16.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.2% |
21.1%
6.1 pts worse
|
16.3%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.9% |
17.3%
6.6 pts worse
|
14.9%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
2.3%
About the same
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
3.0%
1.4 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.6% |
25.5%
8.1 pts worse
|
19.8%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
5.5%
0.4 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
86.8%
6 pts better
|
81.7%
11.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
15.0%
5.9 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.3%
0.7 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.3% |
82.2%
5.1 pts better
|
79.7%
7.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.5% |
22.7%
5.2 pts better
|
23.9%
6.4 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-07 · Fire 2023-11-07
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-09-22 · Fire 2022-09-22
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-18
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-01-20
E · Potential for more than minimal harm
2024-12-18
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-01-20
E · Potential for more than minimal harm
2024-12-18
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-01-20
E · Potential for more than minimal harm
2024-12-18
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-18
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 2025-01-20
D · Potential for more than minimal harm
2024-12-18
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-30
E · Potential for more than minimal harm
2023-11-07
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 2023-11-22
E · Potential for more than minimal harm
2023-11-07
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 2023-11-22
E · Potential for more than minimal harm
2023-11-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-11-22
E · Potential for more than minimal harm
2023-11-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-11-07
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-11-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-11-07
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-11-22
F · Potential for more than minimal harm
2022-09-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-23
E · Potential for more than minimal harm
2022-09-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-09-23
E · Potential for more than minimal harm
2022-09-22
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-09-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-06
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 2025-05-23
K · Immediate jeopardy
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 2024-12-19
G · Actual harm
2024-12-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-20
F · Potential for more than minimal harm
2024-12-18
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 2025-01-20
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 2025-01-20
D · Potential for more than minimal harm
2024-12-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-18
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 2025-01-20
D · Potential for more than minimal harm
2024-12-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-18
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-01-20
D · Potential for more than minimal harm
2022-09-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-10-21
Penalties and ownership
What sits behind the stars
$76,264
2024-12-18
Fine
Fine · fine $76,264
Fine
Ownership
Baumann, Troy
5% Or Greater Direct Ownership Interest · Individual
Hoehn, Jeffrey
5% Or Greater Direct 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
Hardgrove, Paula
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Corporate Director · Individual
Johnson, Juleanna
Operational/Managerial Control · 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
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3-star overall rating with 2-star inspections with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Beaver Dam Health Care Center
Beaver Dam, WI
1-star overall rating with 1-star inspections with abuse icon flag with $144,764 in total fines with 21 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Markesan Resident Home
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5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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