Cycle 1
Health 2024-11-13 · Fire 2024-11-13
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cumberland, WI
Care And Rehab - Cumberland
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
1100 7th Ave, Cumberland, WI
(715) 822-7050
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
50
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Care & Rehab
Operator or chain grouping
Approved since
2013-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 4 staffing / 3 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
0.89
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.66
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.05
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.61
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.96
CMS adjusted RN staffing hours
Adjusted total hours
4.37
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
24%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,609
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9892
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.33% · Performance 21.59% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 9.33% · Performance 9.45% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 31.58% · Performance 8.57% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
4.22
Baseline 4.25 hours · Performance 4.28 hours · Measure score 4.22 · Achievement 4.22 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.55% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 2.44% · Lower 95% interval 5.11% |
| Discharge to community | 49.6% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 47.73% · Lower 95% interval 37.53% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.43% |
95.27%
1.2 pts better
|
Numerator 54 · Denominator 56 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 56 |
| Discharge self-care score | 74.42% |
53.69%
20.7 pts better
|
Numerator 32 · Denominator 43 |
| Discharge mobility score | 69.77% |
50.94%
18.8 pts better
|
Numerator 30 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 56 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.45% |
7.12%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 17.14% · Lower 95% interval 4.99% |
| Staff COVID-19 vaccination coverage | 18.03% |
8.2%
9.8 pts better
|
Numerator 11 · Denominator 61 |
| Staff flu vaccination coverage | 82.67% |
42%
40.7 pts better
|
Numerator 62 · Denominator 75 |
| Discharge function score | 69.77% |
56.45%
13.3 pts better
|
Numerator 30 · Denominator 43 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 30 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 51.61% |
25.2%
26.4 pts better
|
Numerator 16 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0 |
1.6
1.6 pts better
|
1.9
1.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.2
0.8 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
95.7%
1.4 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 94.1% · Q3 94.6% · Q4 100.0% · 4Q avg 97.1% |
| 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 | 4.3% |
3.2%
1.1 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 2.9% · Q3 2.7% · Q4 5.3% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.3% |
5.0%
0.3 pts worse
|
11.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 0.0% · Q3 5.7% · Q4 8.8% · 4Q avg 5.3% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
4.9%
2.1 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.1% · Q4 3.6% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.7% |
16.6%
3.9 pts better
|
19.6%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 11.1% · Q3 10.7% · Q4 16.7% · 4Q avg 12.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.1% |
16.7%
9.6 pts better
|
16.7%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 8.7% · Q3 4.3% · Q4 10.0% · 4Q avg 7.1% · 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 | 27.9% |
21.1%
6.8 pts worse
|
16.3%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.8% |
17.3%
4.5 pts worse
|
14.9%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 11.1% · Q3 17.9% · Q4 33.3% · 4Q avg 21.8% · 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 0.0% · Q4 5.1% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
3.0%
0.1 pts better
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 2.7% · Q4 5.6% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.7% |
25.5%
4.8 pts better
|
19.8%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 23.6% · Q3 12.5% · Q4 28.2% · 4Q avg 20.7% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
5.5%
1.3 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 0.0% · Q3 5.5% · Q4 4.7% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
86.8%
6.6 pts better
|
81.7%
11.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 96.4% · Q3 93.9% · Q4 89.7% · 4Q avg 93.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.1% |
15.0%
0.9 pts better
|
12.0%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 12.9% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.1% |
82.2%
6.9 pts better
|
79.7%
9.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
22.7%
1 pts worse
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 19.4% · Expected 19.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-07 · Fire 2023-09-07
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-08-10 · Fire 2022-08-10
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-13
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-12-17
F · Potential for more than minimal harm
2024-11-13
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-13
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-13
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 2024-12-17
E · Potential for more than minimal harm
2024-11-13
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-13
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-17
F · Potential for more than minimal harm
2023-09-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-07
F · Potential for more than minimal harm
2023-09-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-07
F · Potential for more than minimal harm
2023-09-07
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 2023-10-07
D · Potential for more than minimal harm
2023-09-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-07
F · Potential for more than minimal harm
2022-08-10
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-09-10
F · Potential for more than minimal harm
2022-08-10
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-09-10
F · Potential for more than minimal harm
2022-08-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-10
E · Potential for more than minimal harm
2022-08-10
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-09-10
E · Potential for more than minimal harm
2022-08-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-10
E · Potential for more than minimal harm
2022-08-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-09-10
D · Potential for more than minimal harm
2022-08-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-09-10
D · Potential for more than minimal harm
2022-08-10
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2022-09-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-18
E · Potential for more than minimal harm
2025-07-07
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 2025-08-07
D · Potential for more than minimal harm
2024-11-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-13
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 2024-12-13
D · Potential for more than minimal harm
2024-11-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-12-13
D · Potential for more than minimal harm
2023-09-07
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-10-07
D · Potential for more than minimal harm
2023-09-07
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 2023-10-07
D · Potential for more than minimal harm
2023-09-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-10-07
D · Potential for more than minimal harm
2023-09-07
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 2023-10-07
D · Potential for more than minimal harm
2023-09-07
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 2023-10-07
D · Potential for more than minimal harm
2023-09-07
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 2023-10-07
D · Potential for more than minimal harm
2023-09-07
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 2023-10-07
D · Potential for more than minimal harm
2023-09-07
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 2023-10-07
D · Potential for more than minimal harm
2022-08-10
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-09-10
D · Potential for more than minimal harm
2022-08-10
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 2022-09-10
D · Potential for more than minimal harm
2022-08-10
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 2022-09-10
Penalties and ownership
What sits behind the stars
Ownership
Thayer, Grant
5% Or Greater Direct Ownership Interest · Individual
Bechtel, Jessica
Operational/Managerial Control · Individual
Corton, Nicola
Operational/Managerial Control · Individual
Lingen, Thomas
Operational/Managerial Control · Individual
Sadowska, Timothy
Operational/Managerial Control · Individual
Senior Management Inc
Operational/Managerial Control · Organization
Thayer, Grant
Operational/Managerial Control · Individual
Thayer, Grant
Corporate Director · Individual
Voeltz, Kristin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Barron Care And Rehabilitation
Barron, WI
2-star overall rating with 2-star inspections with $7,446 in total fines with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Dove Healthcare - Rice Lake
Rice Lake, WI
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Heritage Lakeside
Rice Lake, WI
1-star overall rating with 1-star inspections with $115,181 in total fines with 21 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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