21 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Beaver Dam, WI
1-star overall rating with 1-star inspections with abuse icon flag with $144,764 in total fines with 21 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
410 Roedl Ct, Beaver Dam, WI
(920) 887-7191
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
90
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bedrock Healthcare
Operator or chain grouping
Approved since
1983-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.35
Registered nurse staffing
LPN hours / resident day
0.66
Licensed practical nurse staffing
Aide hours / resident day
1.60
Nurse aide staffing
Weekend hours
2.42
Weekend nurse staffing
RN turnover
46%
Annual RN turnover
Total nurse turnover
61%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.6% |
95.7%
5.1 pts worse
|
93.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.7% |
95.0%
1.3 pts worse
|
95.5%
1.8 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.2%
0.5 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 5.8% |
4.9%
0.9 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.8% |
16.6%
3.8 pts better
|
19.6%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 27.3% |
16.7%
10.6 pts worse
|
16.7%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.4% |
21.1%
12.7 pts better
|
16.3%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.7% |
17.3%
10.6 pts better
|
14.9%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
2.3%
1.7 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
3.0%
2.1 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.7% |
25.5%
6.8 pts better
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 12.7% |
5.5%
7.2 pts worse
|
5.1%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.9% |
86.8%
14.9 pts worse
|
81.7%
9.8 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 28.5% |
15.0%
13.5 pts worse
|
12.0%
16.5 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.3%
1.3 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.0% |
82.2%
9.2 pts worse
|
79.7%
6.7 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
22.7%
6.1 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Quality of Life and Care (8 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Top issue: Quality of Life and Care (8 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (16 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-03-26
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 2025-03-26
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 2025-03-26
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-26
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-26
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-03-26
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-03-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-26
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-26
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-26
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-26
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-04-03
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-03
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-03
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-03
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-03
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-04-03
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-03
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 2024-04-03
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-03
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-03
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-16
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-16
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-16
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 2023-01-16
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-16
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-01-16
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-01-16
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-12
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-12
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-14
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-14
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 2025-04-14
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-14
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-27
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-27
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-27
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-03-27
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-03-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-27
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 2025-03-27
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-03-27
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-27
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-27
Health
Provide activities to meet all resident's needs.
Corrected 2025-03-27
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-27
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 2025-03-27
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-27
Health
Implement a program that monitors antibiotic use.
Corrected 2025-03-27
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-23
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2024-08-06
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-06
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-25
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-25
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-07-25
Health
Provide activities to meet all resident's needs.
Corrected 2024-07-25
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-07-25
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-25
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-25
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-07-25
Health
Post nurse staffing information every day.
Corrected 2024-07-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-03
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-03
Health
Implement a program that monitors antibiotic use.
Corrected 2024-04-03
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-04-03
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-04-03
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-03
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-03
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-03
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-03
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 2024-04-03
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-03
Health
Keep all essential equipment working safely.
Corrected 2024-04-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-13
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-28
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-02-16
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-16
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-13
Health
Provide activities to meet all resident's needs.
Corrected 2024-02-13
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 2024-02-16
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-02-28
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-08
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-08
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-08
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-08
Health
Help the resident with transportation to and from laboratory services outside of the facility.
Corrected 2024-01-08
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-20
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-20
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-11-20
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-18
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-10
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-01
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-06-01
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-06-01
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-01
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-05-15
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-17
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-16
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-16
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-16
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-01-16
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-01-16
Health
Respond appropriately to all alleged violations.
Corrected 2023-01-16
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-01-16
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2023-01-16
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-01-16
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2023-01-16
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-01-16
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-01-16
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-01-16
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-01-16
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-01-16
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-16
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-01-16
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-01-16
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-01-16
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-01-16
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-01-16
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-01-16
Penalties and ownership
Payment Denial · denial start 2025-03-27 · 18 days
18 day denial
Fine · fine $46,258
Fine
Payment Denial · denial start 2024-07-25 · 12 days
12 day denial
Fine · fine $49,526
Fine
Payment Denial · denial start 2024-02-20 · 8 days
8 day denial
Fine · fine $11,464
Fine
Fine · fine $37,516
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
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