Cycle 1
Health 2025-10-02 · Fire 2025-10-02
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Wausau, WI
Wausau Manor Health Services
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3107 Westhill Dr, Wausau, WI
(715) 842-0575
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
68
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1984-05-14
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
1.13
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.39
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.73
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.20
CMS adjusted RN staffing hours
Adjusted total hours
3.98
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
29%
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
6,463
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.77
Composite VBP score used to determine payment impact.
Payment multiplier
0.9873
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.77
Baseline 17.45% · Performance 20.15% · Measure score 2.77 · Achievement 2.77 · Improvement 0
Healthcare-associated infections
2.97
Baseline 6.83% · Performance 6.95% · Measure score 2.97 · Achievement 2.97 · Improvement 0
Total nurse turnover
6.20
Baseline 49.02% · Performance 38.33% · Measure score 6.20 · Achievement 6.20 · Improvement 3.92
Adjusted total nurse staffing
1.16
Baseline 3.36 hours · Performance 3.41 hours · Measure score 1.16 · Achievement 1.16 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.09% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 118 · Observed rate 8.47% · Lower 95% interval 7.39% |
| Discharge to community | 53.13% |
50.57%
2.6 pts better
|
No Different than the National Rate · Eligible stays 117 · Observed rate 47.86% · Lower 95% interval 44.5% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.36% |
95.27%
3.1 pts better
|
Numerator 60 · Denominator 61 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 61 |
| Discharge self-care score | 36.96% |
53.69%
16.7 pts worse
|
Numerator 17 · Denominator 46 |
| Discharge mobility score | 28.26% |
50.94%
22.7 pts worse
|
Numerator 13 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 4.92% |
2.29%
2.6 pts worse
|
Numerator 3 · Denominator 61 · Adjusted rate 3.78% |
| Healthcare-associated infections requiring hospitalization | 6.95% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 6.45% · Lower 95% interval 4.16% |
| Staff COVID-19 vaccination coverage | 13.92% |
8.2%
5.7 pts better
|
Numerator 11 · Denominator 79 |
| Staff flu vaccination coverage | 56.25% |
42%
14.2 pts better
|
Numerator 45 · Denominator 80 |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 24 · Denominator 46 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 89.66% |
96.28%
6.6 pts worse
|
Numerator 26 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 23.08% |
25.2%
2.1 pts worse
|
Numerator 6 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.6 · 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 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
95.7%
0.9 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.8% · Q3 93.2% · Q4 95.5% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.0% |
95.0%
1 pts worse
|
95.5%
1.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.2%
0.2 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 4.3% · Q3 2.3% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
5.0%
3 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
4.9%
2 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.4% · Q3 5.6% · Q4 0.0% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.9% |
16.6%
8.7 pts better
|
19.6%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 5.4% · Q3 5.6% · Q4 13.5% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.1% |
16.7%
4.4 pts worse
|
16.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 19.2% · Q3 22.6% · Q4 19.4% · 4Q avg 21.1% · 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 | 21.2% |
21.1%
0.1 pts worse
|
16.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.2% |
17.3%
4.9 pts worse
|
14.9%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 29.7% · Q3 17.6% · Q4 26.5% · 4Q avg 22.2% · Used in QM five-star |
| 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 · Q1 1.6% · Q2 2.7% · Q3 1.8% · Q4 3.1% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
3.0%
2.4 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.0% |
25.5%
1.5 pts better
|
19.8%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 22.2% · Q3 24.7% · Q4 20.6% · 4Q avg 24.0% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
5.5%
2.4 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 9.2% · Q3 9.7% · Q4 8.0% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.3% |
86.8%
1.5 pts better
|
81.7%
6.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 92.5% · Q3 79.8% · Q4 85.2% · 4Q avg 88.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
15.0%
5.5 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 9.3% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.3%
0.5 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 5.6% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.7% |
82.2%
3.5 pts better
|
79.7%
6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.3% |
22.7%
2.4 pts better
|
23.9%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.3% · Observed 22.2% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-08-17 · Fire 2023-08-17
2 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-10-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-12-15
E · Potential for more than minimal harm
2025-10-02
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-12-15
E · Potential for more than minimal harm
2024-08-15
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 2024-09-14
E · Potential for more than minimal harm
2024-08-15
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 2024-09-14
D · Potential for more than minimal harm
2024-08-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-14
D · Potential for more than minimal harm
2024-08-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-14
C · Minimal harm
2024-08-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-14
F · Potential for more than minimal harm
2023-08-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-17
E · Potential for more than minimal harm
2023-08-17
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-09-17
D · Potential for more than minimal harm
2023-08-17
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 2023-09-17
D · Potential for more than minimal harm
2023-08-17
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-09-17
D · Potential for more than minimal harm
2023-08-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-17
D · Potential for more than minimal harm
2023-08-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-17
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-10-02
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 2025-12-12
F · Potential for more than minimal harm
2025-10-02
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-12-12
E · Potential for more than minimal harm
2025-10-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-10-02
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 2025-12-12
D · Potential for more than minimal harm
2025-10-02
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 2025-12-12
D · Potential for more than minimal harm
2025-10-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-10-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-10-02
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 2025-12-12
D · Potential for more than minimal harm
2025-08-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-09-21
D · Potential for more than minimal harm
2025-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-21
D · Potential for more than minimal harm
2025-07-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-08-01
C · Minimal harm
2024-08-15
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-09-14
F · Potential for more than minimal harm
2023-08-17
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 2023-09-15
D · Potential for more than minimal harm
2023-08-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-15
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
Wood Aven Health and Rehabilitation
Wausau, WI
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Amethyst Health Of Wausau
Wausau, WI
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $96,300 in total fines with 24 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
North Central Health Care
Wausau, WI
2-star overall rating with 2-star inspections with $13,627 in total fines with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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