Cycle 1
Health 2025-12-10 · Fire 2025-12-10
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Baldwin, WI
Baldwin Care Center
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
650 Birch St, Baldwin, WI
(715) 684-3231
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
33
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-01-01
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
0.89
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.72
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.85
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.66
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
1.02
CMS adjusted RN staffing hours
Adjusted total hours
4.99
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,159
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.37
Composite VBP score used to determine payment impact.
Payment multiplier
1.0057
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
4.51
Baseline 46.30% · Performance 45.24% · Measure score 4.51 · Achievement 4.51 · Improvement 0
Adjusted total nurse staffing
5.76
Baseline 5.17 hours · Performance 4.72 hours · Measure score 5.76 · Achievement 5.76 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 5.26% · Lower 95% interval 6.07% |
| Discharge to community | 50.2% |
50.57%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 45.71% · Lower 95% interval 38.23% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 95.65% |
95.27%
0.4 pts better
|
Numerator 22 · Denominator 23 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 23 |
| Discharge self-care score | 60% |
53.69%
6.3 pts better
|
Numerator 12 · Denominator 20 |
| Discharge mobility score | 75% |
50.94%
24.1 pts better
|
Numerator 15 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 23 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.32% |
8.2%
2.9 pts worse
|
Numerator 5 · Denominator 94 |
| Staff flu vaccination coverage | 53.41% |
42%
11.4 pts better
|
Numerator 47 · Denominator 88 |
| Discharge function score | 70% |
56.45%
13.5 pts better
|
Numerator 14 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.2
0.6 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
95.7%
0.8 pts worse
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 93.9% · Q3 94.3% · Q4 93.8% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 79.5% |
95.0%
15.5 pts worse
|
95.5%
16 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 79.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.2%
0.3 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 5.7% · Q4 3.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.5% |
5.0%
6.5 pts worse
|
11.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 7.4% · Q3 19.4% · Q4 7.7% · 4Q avg 11.5% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
4.9%
1.2 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.8% · Q3 6.9% · Q4 0.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.1% |
16.6%
7.5 pts better
|
19.6%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 14.8% · Q3 6.9% · Q4 3.7% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
16.7%
10.5 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q3 4.5% · 4Q avg 6.2% · 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 | 24.5% |
21.1%
3.4 pts worse
|
16.3%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.6% |
17.3%
6.3 pts worse
|
14.9%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 18.5% · Q3 20.7% · Q4 25.9% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
2.3%
1 pts better
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 2.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.4% |
3.0%
4.4 pts worse
|
1.7%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.2% · Q3 8.6% · Q4 9.4% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.2% |
25.5%
11.3 pts better
|
19.8%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 12.0% · Q3 16.1% · Q4 5.8% · 4Q avg 14.2% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.5%
2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.0% · Q3 2.2% · Q4 2.4% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.7% |
86.8%
7.1 pts worse
|
81.7%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 79.7% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.9% |
1.3%
3.6 pts worse
|
1.6%
3.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-08 · Fire 2024-08-08
5 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-08-17 · Fire 2023-08-17
8 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-10
F · Potential for more than minimal harm
2025-12-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-10
F · Potential for more than minimal harm
2025-12-10
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 2026-01-10
D · Potential for more than minimal harm
2025-12-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-01-10
F · Potential for more than minimal harm
2024-08-08
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 2024-09-01
F · Potential for more than minimal harm
2024-08-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-01
F · Potential for more than minimal harm
2024-08-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-08-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-01
F · Potential for more than minimal harm
2023-08-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-17
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 2023-09-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-10
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 2026-01-10
F · Potential for more than minimal harm
2025-12-10
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-10
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-10
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 2026-01-10
D · Potential for more than minimal harm
2025-12-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-10
F · Potential for more than minimal harm
2024-08-08
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 2024-09-01
F · Potential for more than minimal harm
2024-08-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-08-08
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 2024-09-01
D · Potential for more than minimal harm
2024-08-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-08-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-09-01
F · Potential for more than minimal harm
2023-08-17
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 2023-09-15
D · Potential for more than minimal harm
2023-08-17
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 2023-09-15
D · Potential for more than minimal harm
2023-08-17
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-17
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 2023-09-15
D · Potential for more than minimal harm
2023-08-17
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 2023-09-15
D · Potential for more than minimal harm
2023-08-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-15
Penalties and ownership
What sits behind the stars
Ownership
Flug-Geissler, Erin
Corporate Director · Individual
Hayes, Donna
Corporate Director · Individual
Hutchins, Grant
Corporate Director · Individual
Jacobson, Mary
Corporate Director · Individual
Klopp, Jason
Corporate Director · Individual
Lafavor, Eileen
Corporate Director · Individual
Mikla, Sheila
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Hammond Health Services
Hammond, WI
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Park View Home
Woodville, WI
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Spring Valley Health And Rehab Center
Spring Valley, WI
2-star overall rating with 2-star inspections with $27,690 in total fines with 14 recent health deficiencies
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