Cycle 1
Health 2024-10-23 · Fire 2024-10-23
13 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Grantsburg, WI
Burnett Medical Center
2-star overall rating with 3-star inspections with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
257 W St George Ave, Grantsburg, WI
(715) 463-5353
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
24
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-03-01
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.25
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.43
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.93
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.62
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.68
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.67
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.66
CMS adjusted RN staffing hours
Adjusted total hours
7.45
CMS adjusted total nurse staffing hours
Case-mix index
1.03
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
846
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.04
Composite VBP score used to determine payment impact.
Payment multiplier
1.0178
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
7.19
Baseline 33.33% · Performance 34.29% · Measure score 7.19 · Achievement 7.19 · Improvement 0
Adjusted total nurse staffing
5.42
Baseline 4.12 hours · Performance 4.62 hours · Measure score 5.42 · Achievement 5.42 · Improvement 2.49
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 9 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.17% |
8.2%
3 pts worse
|
Numerator 3 · Denominator 58 |
| Staff flu vaccination coverage | 58.82% |
42%
16.8 pts better
|
Numerator 40 · Denominator 68 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 62.4% |
95.7%
33.3 pts worse
|
93.4%
31 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 59.3% · Q3 33.3% · Q4 54.2% · 4Q avg 62.4% |
| 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 | 6.9% |
3.2%
3.7 pts worse
|
3.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.4% · Q3 8.3% · Q4 8.3% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
5.0%
0.2 pts worse
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.7% · Q3 4.5% · Q4 0.0% · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
4.9%
2.5 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 4.5% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.0% |
16.6%
5.6 pts better
|
19.6%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 8.7% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.9% |
16.7%
0.2 pts worse
|
16.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.9% · 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 | 22.4% |
21.1%
1.3 pts worse
|
16.3%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.9% |
17.3%
15.6 pts worse
|
14.9%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 57.1% · Q2 25.0% · 4Q avg 32.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
2.3%
0.7 pts better
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 1.6% · 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 3.8% · Q2 0.0% · Q3 4.2% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
25.5%
1 pts better
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 30.4% · Q3 27.1% · Q4 7.9% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
5.5%
1.9 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 15.6% · Q4 15.3% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.3% |
86.8%
8.5 pts worse
|
81.7%
3.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 78.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-26 · Fire 2023-07-26
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-06-16 · Fire 2022-06-16
10 health deficiencies
Top issue: Infection Control (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-31
E · Potential for more than minimal harm
2023-07-26
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 2023-09-08
E · Potential for more than minimal harm
2023-07-26
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-08
C · Minimal harm
2023-07-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-08
C · Minimal harm
2023-07-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-08
F · Potential for more than minimal harm
2022-06-16
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-08-01
F · Potential for more than minimal harm
2022-06-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-01
E · Potential for more than minimal harm
2022-06-16
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-08-01
E · Potential for more than minimal harm
2022-06-16
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-08-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-08
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Not marked corrected
D · Potential for more than minimal harm
2026-01-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Not marked corrected
D · Potential for more than minimal harm
2025-10-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-11
F · Potential for more than minimal harm
2024-10-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-10-23
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 2024-11-22
D · Potential for more than minimal harm
2024-10-23
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 2024-11-22
D · Potential for more than minimal harm
2024-10-23
F585 · Resident Rights Deficiencies
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 2024-11-22
D · Potential for more than minimal harm
2024-10-23
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 2024-11-22
D · Potential for more than minimal harm
2024-10-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-23
F756 · Pharmacy Service Deficiencies
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 2024-11-22
D · Potential for more than minimal harm
2024-10-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-22
D · Potential for more than minimal harm
2023-12-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-27
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 2024-01-18
D · Potential for more than minimal harm
2023-09-18
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 2023-10-19
E · Potential for more than minimal harm
2023-07-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-26
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 2023-08-26
D · Potential for more than minimal harm
2023-07-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-26
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-26
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 2023-08-26
D · Potential for more than minimal harm
2023-07-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-26
F · Potential for more than minimal harm
2022-06-16
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 2022-08-01
E · Potential for more than minimal harm
2022-06-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-08-01
E · Potential for more than minimal harm
2022-06-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-01
E · Potential for more than minimal harm
2022-06-16
F887 · Infection Control Deficiencies
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 2022-08-01
E · Potential for more than minimal harm
2022-06-16
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-08-01
Penalties and ownership
What sits behind the stars
Ownership
Benson, Ryan
Corporate Officer · Individual
Bremer Bank, National Association
5% Or Greater Mortgage Interest · Organization
Carey, Randy
Corporate Director · Individual
Carlson, Lois
Corporate Director · Individual
Fiedler, Julie
Corporate Director · Individual
Hoefs, Jennifer
W-2 Managing Employee · Individual
Lewis, Gordon
Corporate Officer · Individual
Lewis, Gordon
W-2 Managing Employee · Individual
Mcintosh, Stuart
W-2 Managing Employee · Individual
Mckenzie, Julie
W-2 Managing Employee · Individual
Novick, Timothy
W-2 Managing Employee · Individual
Sybers, Christopher
Corporate Director · Individual
Taylor, Patrick
Corporate Officer · Individual
White, Tamra
Operational/Managerial Control · Individual
White, Tamra
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Frederic, WI
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
The Estates at Rush City LLC
Rush City, MN
3-star overall rating with 3-star inspections with 7 recent health deficiencies
#3
United Pioneer Home
Luck, WI
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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