Cycle 1
Health 2025-03-12 · Fire 2025-03-12
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Mondovi, WI
American Lutheran Home-Mondovi
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
200 Memorial Dr, Mondovi, WI
(715) 926-4962
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
35
Certified beds
Average residents
19
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-04-01
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
1.18
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
2.57
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.11
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.82
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.96
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.25
CMS adjusted RN staffing hours
Adjusted total hours
4.33
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
27%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,770
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.85
Composite VBP score used to determine payment impact.
Payment multiplier
1.0015
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.11
Baseline 19.26% · Performance 18.60% · Measure score 6.11 · Achievement 6.11 · Improvement 2.48
Healthcare-associated infections
0
Baseline 6.43% · Performance 7.85% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.24
Baseline 23.81% · Performance 30.00% · Measure score 8.24 · Achievement 8.24 · Improvement 0
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.15% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 9.38% · Lower 95% interval 6.52% |
| Discharge to community | 49.25% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 43.64% · Lower 95% interval 37.15% |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 43 · Denominator 43 |
| Falls with major injury | 4.65% |
0.77%
3.9 pts worse
|
Numerator 2 · Denominator 43 |
| Discharge self-care score | 30.56% |
53.69%
23.1 pts worse
|
Numerator 11 · Denominator 36 |
| Discharge mobility score | 25% |
50.94%
25.9 pts worse
|
Numerator 9 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 4.65% |
2.29%
2.4 pts worse
|
Numerator 2 · Denominator 43 · Adjusted rate 6.75% |
| Healthcare-associated infections requiring hospitalization | 7.85% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 10.53% · Lower 95% interval 4.33% |
| Staff COVID-19 vaccination coverage | 12.24% |
8.2%
4 pts better
|
Numerator 6 · Denominator 49 |
| Staff flu vaccination coverage | 68.67% |
42%
26.7 pts better
|
Numerator 57 · Denominator 83 |
| Discharge function score | 41.67% |
56.45%
14.8 pts worse
|
Numerator 15 · Denominator 36 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 59.26% |
25.2%
34.1 pts better
|
Numerator 16 · Denominator 27 |
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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.5% |
3.2%
7.3 pts worse
|
3.3%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.5% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
4.9%
4 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
16.6%
1.8 pts worse
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
16.7%
16.7 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.7% |
21.1%
10.4 pts better
|
16.3%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.4% |
17.3%
6.9 pts better
|
14.9%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.4% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.0%
3 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.8% |
25.5%
8.7 pts better
|
19.8%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.8% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
5.5%
3.3 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
86.8%
7.3 pts better
|
81.7%
12.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.7% · Q2 89.2% · Q3 97.7% · Q4 100.0% · 4Q avg 94.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.9% |
15.0%
12.1 pts better
|
12.0%
9.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.9% · Observed 2.5% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.3%
0.6 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 3.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.7% |
82.2%
7.5 pts better
|
79.7%
10 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.9% |
22.7%
6.8 pts better
|
23.9%
8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 12.5% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-14 · Fire 2024-02-14
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-12-08 · Fire 2022-12-08
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-12
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-04-24
E · Potential for more than minimal harm
2025-03-12
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-04-24
E · Potential for more than minimal harm
2025-03-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-12
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-12
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
2025-03-12
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-24
F · Potential for more than minimal harm
2024-02-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-08
F · Potential for more than minimal harm
2022-12-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-12
D · Potential for more than minimal harm
2022-12-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-12
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 2025-04-02
D · Potential for more than minimal harm
2025-03-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-02
F · Potential for more than minimal harm
2024-02-14
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 2024-03-06
E · Potential for more than minimal harm
2024-02-14
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 2024-03-06
D · Potential for more than minimal harm
2024-02-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-06
Penalties and ownership
What sits behind the stars
Ownership
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
Hungerford, Kevin
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
Lee, Rita
Corporate Director · Individual
Lilyquist, Jenny
Operational/Managerial Control · Individual
Lisowski, Tonya
Operational/Managerial Control · Individual
Reid, Anita
Corporate Director · Individual
Rich, Trevor
Operational/Managerial Control · Individual
Tande, Chelsea
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Dove Healthcare - South Eau Claire
Eau Claire, WI
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Grace Lutheran Communities - River Pines
Altoona, WI
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Dove Healthcare - West Eau Claire
Eau Claire, WI
5-star overall rating with 3-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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