Cycle 1
Health 2025-08-13 · Fire 2025-08-13
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Sheboygan, WI
Sheboygan Progressive Health Services
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1902 Mead Ave, Sheboygan, WI
(920) 458-8333
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
50
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1993-03-01
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
0.90
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.33
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.71
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
0.90
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,232
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.37% · Performance 21.68% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.03% · Performance 7.96% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.42
Baseline 41.51% · Performance 29.27% · Measure score 8.42 · Achievement 8.42 · Improvement 6.85
Adjusted total nurse staffing
0
Baseline 3.01 hours · Performance 3.12 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.07% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 7.27% · Lower 95% interval 5.69% |
| Discharge to community | 47.59% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 42.11% · Lower 95% interval 33.77% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 88.24% |
95.27%
7 pts worse
|
Numerator 30 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | 28% |
53.69%
25.7 pts worse
|
Numerator 7 · Denominator 25 |
| Discharge mobility score | 24% |
50.94%
26.9 pts worse
|
Numerator 6 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 5.88% |
2.29%
3.6 pts worse
|
Numerator 2 · Denominator 34 · Adjusted rate 5.24% |
| Healthcare-associated infections requiring hospitalization | 7.96% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 4.18% |
| Staff COVID-19 vaccination coverage | 4% |
8.2%
4.2 pts worse
|
Numerator 2 · Denominator 50 |
| Staff flu vaccination coverage | 43.1% |
42%
1.1 pts better
|
Numerator 25 · Denominator 58 |
| Discharge function score | 32% |
56.45%
24.5 pts worse
|
Numerator 8 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · 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 | 1.7 |
1.6
0.1 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.1 · Expected 1.2 · 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 0.7 · Expected 1.3 · 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 | 1.4% |
3.2%
1.8 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 2.6% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
5.0%
2.2 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 0.0% · Q3 5.1% · Q4 0.0% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
4.9%
3.1 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% |
| 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 11.1% · Q2 7.1% · Q3 15.6% · Q4 19.4% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
16.7%
5.5 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.5% · Q3 14.3% · Q4 12.0% · 4Q avg 11.2% · 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 | 34.3% |
21.1%
13.2 pts worse
|
16.3%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.5% |
17.3%
5.2 pts worse
|
14.9%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 25.9% · Q3 13.3% · Q4 13.8% · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
2.3%
0.8 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 3.3% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
3.0%
1.6 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.7% |
25.5%
7.2 pts worse
|
19.8%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 34.1% · Q3 21.9% · Q4 47.5% · 4Q avg 32.7% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.5%
1 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 15.6% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
86.8%
8.9 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 96.7% · Q3 95.6% · Q4 94.4% · 4Q avg 95.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.7% |
15.0%
6.7 pts worse
|
12.0%
9.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 18.8% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.1% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.5% |
82.2%
11.7 pts worse
|
79.7%
9.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.9% |
22.7%
7.8 pts better
|
23.9%
9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 12.5% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-19 · Fire 2024-06-19
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-04-05 · Fire 2023-04-05
9 health deficiencies
Top issue: Nursing and Physician Services (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-13
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-09-08
F · Potential for more than minimal harm
2025-08-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-06-01
F · Potential for more than minimal harm
2025-08-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
F · Potential for more than minimal harm
2025-08-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-09-05
F · Potential for more than minimal harm
2025-08-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-25
E · Potential for more than minimal harm
2025-08-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-08-19
D · Potential for more than minimal harm
2025-08-13
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 2025-08-29
F · Potential for more than minimal harm
2024-06-19
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
2024-06-19
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-19
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 2024-07-17
E · Potential for more than minimal harm
2023-04-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-04-05
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-04-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-02-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-27
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 2025-03-21
F · Potential for more than minimal harm
2024-06-19
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 2024-07-17
D · Potential for more than minimal harm
2024-06-19
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-19
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 2024-07-17
D · Potential for more than minimal harm
2024-03-13
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-03-29
E · Potential for more than minimal harm
2023-07-12
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-07-12
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-01
G · Actual harm
2023-04-05
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 2023-05-03
D · Potential for more than minimal harm
2023-04-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-04-05
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 2023-05-03
D · Potential for more than minimal harm
2023-04-05
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 2023-05-03
D · Potential for more than minimal harm
2023-04-05
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-04-05
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-05-03
C · Minimal harm
2023-04-05
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-05-03
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
Corporate Director · Individual
Baumann, Troy
W-2 Managing Employee · Individual
Hoehn, Jeffrey
Corporate Director · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Meadow View Health Services
Sheboygan, WI
5-star overall rating with 4-star inspections with 4 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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