Cycle 1
Health 2025-12-04 · Fire 2025-12-04
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Mayville, WI
Avina of Mayville
4-star overall rating with 3-star inspections with $19,383 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
305 S. Clark St., Mayville, WI
(920) 387-0354
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avina Healthcare
Operator or chain grouping
Approved since
1997-03-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.81
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.79
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
3.25
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,741
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.17
Baseline 18.65% · Performance 19.96% · Measure score 3.17 · Achievement 3.17 · Improvement 0
Healthcare-associated infections
0
Baseline 6.05% · Performance 8.37% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.44
Baseline 96.88% · Performance 61.29% · Measure score 4.44 · Achievement 0.58 · Improvement 4.44
Adjusted total nurse staffing
2.71
Baseline 2.25 hours · Performance 3.39 hours · Measure score 2.71 · Achievement 1.09 · Improvement 2.71
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.16% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 5.8% · Lower 95% interval 6.1% |
| Discharge to community | 50.46% |
50.57%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 42.19% · Lower 95% interval 35.95% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 38 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 56.67% |
53.69%
3 pts better
|
Numerator 17 · Denominator 30 |
| Discharge mobility score | 43.33% |
50.94%
7.6 pts worse
|
Numerator 13 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 38 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.37% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 15.15% · Lower 95% interval 4.75% |
| Staff COVID-19 vaccination coverage | 4% |
8.2%
4.2 pts worse
|
Numerator 3 · Denominator 75 |
| Staff flu vaccination coverage | 36.63% |
42%
5.4 pts worse
|
Numerator 37 · Denominator 101 |
| Discharge function score | 63.33% |
56.45%
6.9 pts better
|
Numerator 19 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 39.13% |
25.2%
13.9 pts better
|
Numerator 9 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.2
0.2 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.5% |
95.7%
3.2 pts worse
|
93.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.7% · Q3 88.4% · Q4 84.8% · 4Q avg 92.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
95.0%
3.1 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
3.2%
2.6 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
5.0%
1.2 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 10.0% · Q4 4.8% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
4.9%
0.2 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 8.3% · Q3 2.6% · Q4 0.0% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.3% |
16.6%
5.3 pts better
|
19.6%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 13.5% · Q3 7.9% · Q4 5.0% · 4Q avg 11.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.8% |
16.7%
5.9 pts better
|
16.7%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 11.5% · Q3 13.8% · Q4 12.5% · 4Q avg 10.8% · 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 | 12.4% |
21.1%
8.7 pts better
|
16.3%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.6% |
17.3%
5.7 pts better
|
14.9%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.1% · Q3 10.8% · Q4 23.1% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
2.3%
1.6 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · 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 2.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.1% |
25.5%
11.4 pts better
|
19.8%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 14.7% · Q3 14.5% · Q4 17.3% · 4Q avg 14.1% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.5%
0.9 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 1.8% · Q3 5.3% · Q4 6.8% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
86.8%
9.2 pts better
|
81.7%
14.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 98.5% · Q3 97.3% · Q4 91.0% · 4Q avg 96.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
15.0%
7.6 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 8.0% · Expected 12.0% · 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 · Q1 3.1% · Q2 2.8% · Q3 2.3% · 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 | 89.0% |
82.2%
6.8 pts better
|
79.7%
9.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 8.5% |
22.7%
14.2 pts better
|
23.9%
15.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 8.0% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
14 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2023-04-25 · Fire 2023-04-25
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-04
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2026-01-02
F · Potential for more than minimal harm
2025-12-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-01-02
F · Potential for more than minimal harm
2025-12-04
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 2026-01-02
F · Potential for more than minimal harm
2025-12-04
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2026-01-02
E · Potential for more than minimal harm
2025-12-04
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2026-01-02
F · Potential for more than minimal harm
2024-08-15
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-02
F · Potential for more than minimal harm
2024-08-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-15
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-15
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-09-13
E · 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 2024-09-13
D · Potential for more than minimal harm
2024-08-15
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-15
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2024-09-13
F · Potential for more than minimal harm
2023-04-25
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-05-18
F · Potential for more than minimal harm
2023-04-25
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 2023-05-18
F · Potential for more than minimal harm
2023-04-25
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 2023-05-18
E · Potential for more than minimal harm
2023-04-25
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-05-18
E · Potential for more than minimal harm
2023-04-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-04-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-25
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 2023-05-18
D · Potential for more than minimal harm
2023-04-25
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 2023-05-18
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2026-01-02
F · Potential for more than minimal harm
2025-12-04
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 2026-01-02
E · Potential for more than minimal harm
2025-12-04
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-02
D · Potential for more than minimal harm
2025-12-04
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 2026-01-02
D · Potential for more than minimal harm
2025-12-04
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-01-02
D · Potential for more than minimal harm
2025-12-04
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 2026-01-02
D · Potential for more than minimal harm
2025-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-02
D · Potential for more than minimal harm
2025-07-24
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 2025-08-15
D · Potential for more than minimal harm
2025-02-21
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 2025-03-14
D · Potential for more than minimal harm
2025-02-21
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 2025-03-14
D · Potential for more than minimal harm
2025-02-21
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-03-14
D · Potential for more than minimal harm
2024-10-02
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-10-02
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 2024-10-11
D · Potential for more than minimal harm
2024-08-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-15
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-15
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 2024-09-13
D · Potential for more than minimal harm
2024-08-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-15
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 2024-09-13
G · Actual harm
2023-11-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-09-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-04-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-25
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 2023-05-18
D · Potential for more than minimal harm
2023-04-25
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 2023-05-18
D · Potential for more than minimal harm
2023-04-25
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 2023-05-18
Penalties and ownership
What sits behind the stars
$19,383
2023-11-08
Fine
Fine · fine $19,383
Fine
Ownership
Brandman, Joseph
5% Or Greater Direct Ownership Interest · Individual
Topper, Aaron
5% Or Greater Direct Ownership Interest · Individual
Anderson, Mar'que
Operational/Managerial Control · Individual
Brandman, Joseph
Operational/Managerial Control · Individual
Health Care Management LLC
Operational/Managerial Control · Organization
Ramnanan, Keshni
Operational/Managerial Control · Individual
Topper, Aaron
Operational/Managerial Control · Individual
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#3
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