Cycle 1
Health 2025-03-27 · Fire 2025-03-27
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Williams Bay, WI
Williams Bay Health Services
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
146 Clover St, Williams Bay, WI
(262) 245-6400
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
33
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1984-01-01
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
1.20
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.31
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.46
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
3.07
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.86
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
3.51
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,470
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.74
Baseline 57.14% · Performance 52.50% · Measure score 2.74 · Achievement 2.74 · Improvement 0.94
Adjusted total nurse staffing
0.60
Baseline 3.10 hours · Performance 3.25 hours · Measure score 0.60 · Achievement 0.60 · Improvement 0.04
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.47% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 4.44% · Lower 95% interval 6.14% |
| Discharge to community | 61.01% |
50.57%
10.4 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 56.67% · Lower 95% interval 42.29% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 79.31% |
95.27%
16 pts worse
|
Numerator 23 · Denominator 29 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 29 |
| Discharge self-care score | 35% |
53.69%
18.7 pts worse
|
Numerator 7 · Denominator 20 |
| Discharge mobility score | 25% |
50.94%
25.9 pts worse
|
Numerator 5 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 6.9% |
2.29%
4.6 pts worse
|
Numerator 2 · Denominator 29 · Adjusted rate 5.15% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.64% |
8.2%
4.6 pts worse
|
Numerator 2 · Denominator 55 |
| Staff flu vaccination coverage | 42.86% |
42%
0.9 pts better
|
Numerator 24 · Denominator 56 |
| Discharge function score | 35% |
56.45%
21.5 pts worse
|
Numerator 7 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 30% |
25.2%
4.8 pts better
|
Numerator 6 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
2.2
1.2 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
95.7%
1.7 pts worse
|
93.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 96.6% · Q3 93.1% · Q4 92.9% · 4Q avg 94.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
95.0%
1.7 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.2%
1.5 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 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 who lose too much weight | 8.6% |
4.9%
3.7 pts worse
|
5.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 4.8% · Q3 10.0% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.1% |
16.6%
2.5 pts worse
|
19.6%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 20.8% · Q3 21.7% · 4Q avg 19.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.6% |
16.7%
7.9 pts worse
|
16.7%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.6% · 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 | 45.4% |
21.1%
24.3 pts worse
|
16.3%
29.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 45.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.1% |
17.3%
6.8 pts worse
|
14.9%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 26.1% · Q3 21.7% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
2.3%
1.1 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.9% · Q3 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
3.0%
0.2 pts better
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 0.0% · Q3 3.8% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.7% |
25.5%
9.2 pts worse
|
19.8%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · 4Q avg 34.7% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.5%
2.9 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.1% · Q3 2.7% · Q4 2.5% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.0% |
86.8%
10.8 pts worse
|
81.7%
5.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.3% · Q2 69.2% · Q3 80.0% · Q4 78.3% · 4Q avg 76.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.6% |
15.0%
4.6 pts worse
|
12.0%
7.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 21.7% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.3%
0.3 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.1% |
82.2%
9.1 pts worse
|
79.7%
6.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.4% |
22.7%
6.3 pts better
|
23.9%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 17.4% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-10-03 · Fire 2022-10-03
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-27
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-04-24
F · Potential for more than minimal harm
2025-03-27
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-04-22
E · Potential for more than minimal harm
2025-03-27
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 2025-04-24
D · Potential for more than minimal harm
2025-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-24
C · Minimal harm
2025-03-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-24
F · Potential for more than minimal harm
2024-01-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-21
E · Potential for more than minimal harm
2024-01-25
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-02-21
E · Potential for more than minimal harm
2024-01-25
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-02-21
E · Potential for more than minimal harm
2024-01-25
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-02-21
E · Potential for more than minimal harm
2024-01-25
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-25
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 2024-02-21
D · Potential for more than minimal harm
2024-01-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-21
F · Potential for more than minimal harm
2022-10-03
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-11-01
F · Potential for more than minimal harm
2022-10-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-01
F · Potential for more than minimal harm
2022-10-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-01
F · Potential for more than minimal harm
2022-10-03
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-11-01
E · Potential for more than minimal harm
2022-10-03
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2022-11-01
E · Potential for more than minimal harm
2022-10-03
K233 · Egress Deficiencies
Fire Safety
Install resident room doors of proper design and width.
Corrected 2022-11-01
E · Potential for more than minimal harm
2022-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-26
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 2026-02-23
G · Actual harm
2025-03-27
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 2025-04-24
F · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-24
F · Potential for more than minimal harm
2025-03-27
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-24
D · Potential for more than minimal harm
2023-09-22
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 2023-10-23
D · Potential for more than minimal harm
2023-09-22
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 2023-10-23
D · Potential for more than minimal harm
2023-09-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-23
E · Potential for more than minimal harm
2022-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-01
D · Potential for more than minimal harm
2022-10-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-01
D · Potential for more than minimal harm
2022-10-03
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2022-11-01
D · Potential for more than minimal harm
2022-10-03
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 2022-11-01
Penalties and ownership
What sits behind the stars
Ownership
Nshr Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Arrowhead 123 LLC
5% Or Greater Indirect Ownership Interest · Organization
Baumann, Troy
5% Or Greater Indirect Ownership Interest · Individual
Baumann, Troy
Operational/Managerial Control · Individual
Baumann, Troy
Corporate Director · Individual
Hoehn, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Hoehn, Jeffrey
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Corporate Director · Individual
Mills, David
5% Or Greater Indirect Ownership Interest · Individual
Mills, David
Operational/Managerial Control · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
The Lane Morrell Bowen Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Delavan Health Services
Delavan, WI
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Geneva Lake Manor
Lake Geneva, WI
1-star overall rating with 1-star inspections with $201,107 in total fines with 29 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Golden Years Of Lake Geneva
Lake Geneva, WI
4-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
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