Cycle 1
Health 2026-01-22 · Fire 2026-01-22
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Superior, WI
Twin Ports Health Services
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1612 N 37th St, Superior, WI
(715) 392-5144
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1984-06-14
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
1.15
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.36
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.78
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
1.22
CMS adjusted RN staffing hours
Adjusted total hours
3.71
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
16%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,237
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9859
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.37
Baseline 21.60% · Performance 20.80% · Measure score 1.37 · Achievement 1.37 · Improvement 1.26
Healthcare-associated infections
0
Baseline 6.29% · Performance 8.11% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.94
Baseline 43.42% · Performance 27.16% · Measure score 8.94 · Achievement 8.94 · Improvement 8.26
Adjusted total nurse staffing
1.82
Baseline 3.65 hours · Performance 3.60 hours · Measure score 1.82 · Achievement 1.82 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.67% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 12.28% · Lower 95% interval 7.09% |
| Discharge to community | 38.84% |
50.57%
11.7 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 28.89% · Lower 95% interval 25.82% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.28% |
95.27%
3 pts better
|
Numerator 57 · Denominator 58 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 58 |
| Discharge self-care score | 48.08% |
53.69%
5.6 pts worse
|
Numerator 25 · Denominator 52 |
| Discharge mobility score | 63.46% |
50.94%
12.5 pts better
|
Numerator 33 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 58 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.11% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 12.12% · Lower 95% interval 4.57% |
| Staff COVID-19 vaccination coverage | 4.11% |
8.2%
4.1 pts worse
|
Numerator 6 · Denominator 146 |
| Staff flu vaccination coverage | 64.63% |
42%
22.6 pts better
|
Numerator 95 · Denominator 147 |
| Discharge function score | 63.46% |
56.45%
7 pts better
|
Numerator 33 · Denominator 52 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · 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 | 56.25% |
25.2%
31.1 pts better
|
Numerator 18 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.2
0.3 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.5 · 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 | 3.9% |
3.2%
0.7 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.8% · Q3 4.2% · Q4 5.9% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
5.0%
4.6 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
4.9%
2.3 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 1.9% · Q4 6.1% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.8% |
16.6%
5.8 pts better
|
19.6%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 13.5% · Q3 13.2% · Q4 5.9% · 4Q avg 10.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.5% |
16.7%
4.8 pts worse
|
16.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 25.7% · Q3 21.6% · Q4 18.4% · 4Q avg 21.5% · 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 | 15.6% |
21.1%
5.5 pts better
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 16.3% · Q3 11.8% · Q4 3.9% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.0% |
17.3%
9.3 pts better
|
14.9%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 9.6% · Q3 3.8% · Q4 6.0% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
3.0%
1.2 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 4.2% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.1% |
25.5%
0.6 pts worse
|
19.8%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 37.1% · Q3 25.9% · Q4 26.2% · 4Q avg 26.1% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
5.5%
2.3 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.4% · Q3 1.1% · Q4 4.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
86.8%
10.9 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 97.9% · Q3 98.1% · Q4 97.1% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
15.0%
5.6 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 8.8% · Expected 10.5% · 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 | 98.0% |
82.2%
15.8 pts better
|
79.7%
18.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
22.7%
0.9 pts worse
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 23.5% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-25 · Fire 2024-09-25
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-09-13 · Fire 2023-09-13
2 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2026-01-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-20
F · Potential for more than minimal harm
2024-09-25
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 2024-10-23
F · Potential for more than minimal harm
2024-09-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-19
F · Potential for more than minimal harm
2024-09-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-09-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-23
F · Potential for more than minimal harm
2023-09-13
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-10-11
E · Potential for more than minimal harm
2023-09-13
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 2023-10-11
D · Potential for more than minimal harm
2023-09-13
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-10-11
C · Minimal harm
2023-09-13
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-20
D · Potential for more than minimal harm
2026-01-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-20
D · Potential for more than minimal harm
2026-01-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-20
D · Potential for more than minimal harm
2025-07-18
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 2025-08-15
F · Potential for more than minimal harm
2024-09-25
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 2024-10-23
D · Potential for more than minimal harm
2024-09-25
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 2024-10-23
D · Potential for more than minimal harm
2024-09-25
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 2024-10-23
D · Potential for more than minimal harm
2024-09-25
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 2024-10-23
D · Potential for more than minimal harm
2023-09-13
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 2023-10-11
D · Potential for more than minimal harm
2023-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-11
Penalties and ownership
What sits behind the stars
Ownership
North Shore Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Baumann, Troy
5% Or Greater Direct Ownership Interest · Individual
Baumann, Troy
Operational/Managerial Control · Individual
Baumann, Troy
Corporate Officer · Individual
Hoehn, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Hoehn, Jeffrey
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Corporate Officer · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
Nshc Wisconsin LLC
5% Or Greater Direct Ownership Interest · Organization
Nshc Wisconsin LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Villa Marina Health And Rehab Ctr
Superior, WI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Dove Healthcare - Superior
Superior, WI
2-star overall rating with 2-star inspections with 20 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Franciscan Health Center
Duluth, MN
1-star overall rating with 2-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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