Cycle 1
Health 2025-08-27 · Fire 2025-08-27
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Menomonie, WI
American Lutheran Home-Menomonie
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
915 Elm Ave E, Menomonie, WI
(715) 235-9041
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
37
Certified beds
Average residents
27
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.77
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.57
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.95
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.39
CMS adjusted RN staffing hours
Adjusted total hours
5.29
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,342
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.07
Composite VBP score used to determine payment impact.
Payment multiplier
1.0041
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
5.18
Baseline 47.62% · Performance 42.50% · Measure score 5.18 · Achievement 5.18 · Improvement 1.75
Adjusted total nurse staffing
4.83
Performance 4.45 hours · Measure score 4.83 · Achievement 4.83 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.29% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 7.32% · Lower 95% interval 6.12% |
| Discharge to community | 50.67% |
50.57%
0.1 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 50% · Lower 95% interval 43.5% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 33 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 18 · Denominator 27 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 18 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 1 · Denominator 33 · Adjusted rate 3.89% |
| 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 | 27.14% |
8.2%
18.9 pts better
|
Numerator 19 · Denominator 70 |
| Staff flu vaccination coverage | 54.32% |
42%
12.3 pts better
|
Numerator 44 · Denominator 81 |
| Discharge function score | 74.07% |
56.45%
17.6 pts better
|
Numerator 20 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 9.0% |
3.2%
5.8 pts worse
|
3.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 11.1% · Q3 8.0% · Q4 9.1% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
5.0%
4 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.8% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.9%
4.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.5% |
16.6%
1.1 pts better
|
19.6%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 15.0% · 4Q avg 15.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
16.7%
8.4 pts better
|
16.7%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% · 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 | 22.5% |
21.1%
1.4 pts worse
|
16.3%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.7% |
17.3%
1.6 pts better
|
14.9%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 15.0% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
2.3%
0.9 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.2% · Q3 4.2% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
3.0%
1 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 0.0% · Q4 4.8% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.6% |
25.5%
9.1 pts worse
|
19.8%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.9% · Q2 30.5% · Q3 36.7% · Q4 26.1% · 4Q avg 34.6% |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
5.5%
4.6 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.1% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.8%
13.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 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 | 90.9% |
82.2%
8.7 pts better
|
79.7%
11.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-20 · Fire 2024-06-20
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-05-17 · Fire 2023-05-17
2 health deficiencies
Top issue: Environmental (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-09-27
E · Potential for more than minimal harm
2025-08-27
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 2025-09-27
F · Potential for more than minimal harm
2024-06-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-20
E · Potential for more than minimal harm
2024-06-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-20
F · Potential for more than minimal harm
2023-05-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-27
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-27
G · Actual harm
2024-06-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-20
F · Potential for more than minimal harm
2023-05-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-17
F · Potential for more than minimal harm
2023-05-17
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-06-17
Penalties and ownership
What sits behind the stars
Ownership
Cline, Jeffery
Operational/Managerial Control · Individual
Duhr, Amy
Operational/Managerial Control · Individual
Duhr, Amy
Corporate Officer · Individual
Erickson, Joanne
Corporate Director · Individual
Grace Lutheran Foundation, Inc.
Operational/Managerial Control · Organization
Grossier, Stephany
Corporate Director · Individual
Hazuga, Stacey
Operational/Managerial Control · Individual
Jackson, Tami
Operational/Managerial Control · Individual
Larson, David
Corporate Director · Individual
Larson, Jamie
Operational/Managerial Control · Individual
Larson, Jamie
Corporate Officer · Individual
Larson, Linda
Corporate Director · Individual
Leadingchoice Network LLC
Operational/Managerial Control · Organization
Lee, Rita
Corporate Director · Individual
Phillips, Michael
Operational/Managerial Control · Individual
Reid, Anita
Corporate Director · Individual
Rennock, Randall
Operational/Managerial Control · Individual
Stuart, Ally
Operational/Managerial Control · Individual
Ulberg, Mathew
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Neighbors - Central Neighborhood (The)
Menomonie, WI
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Neighbors - East Neighborhood (The)
Menomonie, WI
3-star overall rating with 3-star inspections with 5 recent health deficiencies
#3
Neighbors - West Neighborhood (The)
Menomonie, WI
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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