Hamilton Health Services
1 Hamilton Dr, Two Rivers, WI 54241 · Manitowoc County · 125 certified beds · avg 21 residents/day · certified since Nov 12, 2001
Part of chain: NORTH SHORE HEALTHCARE (59 facilities, chain avg rating 2.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jul 8, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 29, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (22)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 28, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jan 28, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jan 28, 2026 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Sep 11, 2024 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Sep 11, 2024 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Sep 11, 2024 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Sep 11, 2024 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Sep 11, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Sep 11, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Sep 11, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Sep 11, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Sep 11, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Jul 8, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 8, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jul 8, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jul 8, 2024 | D · Potential for harm, one-off | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. · from a complaint |
| Feb 20, 2024 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. · from a complaint |
| Jul 12, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 12, 2023 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 12, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jul 12, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 12, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (9 → 1).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | F |
| 2024 | 14 | 1 | G ▲ |
| 2026 | 3 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.22 | 4.29 | 3.95 | bottom 12% in Wisconsin; bottom 23% in the U.S. |
| Registered Nurse hours | 0.97 | 1.01 | 0.69 | top 46% in Wisconsin; top 17% in the U.S. |
| Weekend total nurse staffing | 2.91 | 3.84 | 3.50 | bottom 16% in Wisconsin; bottom 26% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.84 | 0.68 | 0.48 | top 23% in Wisconsin; top 10% in the U.S. |
| Total nursing staff turnover (%) | 42.1 | 46.9 | 45.8 | top 37% in Wisconsin; top 42% in the U.S. |
| RN turnover (%) | 50.0 | 39.7 | 42.9 | bottom 36% in Wisconsin; bottom 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.98, RN 1.20, weekend 3.60. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Arrowhead 123 LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 10/01/2019 |
| Mills, David | Individual | 5% or Greater Indirect Ownership Interest | 18% | 10/01/2019 |
| NSHR Operations LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 10/01/2019 |
| The Lane Morrell Bowen Trust | Organization | 5% or Greater Indirect Ownership Interest | 10% | 10/01/2019 |
| Arrowhead 123 LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| Baumann, Troy | Individual | Corporate Director | NOT APPLICABLE | 10/01/2019 |
| Baumann, Troy | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2019 |
| Baumann, Troy | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| Belongia, Christina | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2019 |
| Belongia, Christina | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| Cibc Bank USA | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/31/2024 |
| Cibc Bank USA | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 12/31/2024 |
| Cibc Bank USA | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/31/2024 |
| Cliftonlarsonallen LLP | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2019 |
| Cliftonlarsonallen LLP | Organization | ADP of the SNF | NOT APPLICABLE | 05/23/2025 |
| Continuum Therapy Partners LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| Continuum Therapy Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/23/2025 |
| Gee, Darren | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/30/2021 |
| Gee, Darren | Individual | ADP of the SNF | NOT APPLICABLE | 11/30/2021 |
| Greer, Lauren | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/29/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
- "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
- "If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| North Ridge Health and Rehabilitation Center | 5.8 mi | Manitowoc, WI | ★★☆☆☆ | 2/5 | |
| Shady Lane Nursing Care Center | 7.8 mi | Manitowoc, WI | ★★★★★ | 4/5 | |
| St Marys Home for the Aged | 8.0 mi | Manitowoc, WI | ★★★★★ | 4/5 | |
| River's Bend Health Services | 8.8 mi | Manitowoc, WI | ★★★☆☆ | 3/5 | |
| Complete Care at Manitowoc LLC | 10.8 mi | Manitowoc, WI | ★★★★☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 525664.