Cycle 1
Health 2024-11-13 · Fire 2024-11-13
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Ladysmith, WI
Care & Rehab - Ladysmith 1
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1001 E 11th St N, Ladysmith, WI
(715) 532-5546
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
32
Certified beds
Average residents
29
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Care & Rehab
Operator or chain grouping
Approved since
1996-06-15
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
1.30
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.33
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
4.57
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.01
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.80
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
1.41
CMS adjusted RN staffing hours
Adjusted total hours
4.96
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
13%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
640
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.13
Composite VBP score used to determine payment impact.
Payment multiplier
1.0201
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
8.38
Baseline 56.52% · Performance 29.41% · Measure score 8.38 · Achievement 8.38 · Improvement 8.06
Adjusted total nurse staffing
4.84
Baseline 4.21 hours · Performance 4.46 hours · Measure score 4.84 · Achievement 4.84 · Improvement 1.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 14 · 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 11 · 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 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · 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 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.16% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 86 |
| Staff flu vaccination coverage | 64.1% |
42%
22.1 pts better
|
Numerator 50 · Denominator 78 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
95.7%
2.6 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 96.9% · Q3 100.0% · Q4 100.0% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.4% |
95.0%
3.6 pts worse
|
95.5%
4.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.2%
1 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.2% · Q3 6.7% · Q4 3.6% · 4Q avg 4.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
4.9%
0.3 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 10.3% · Q3 3.6% · Q4 0.0% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.4% |
16.6%
10.2 pts better
|
19.6%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 6.9% · Q3 3.6% · Q4 7.4% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.5% |
16.7%
13.8 pts worse
|
16.7%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.1% · Q2 34.8% · Q3 25.0% · Q4 24.0% · 4Q avg 30.5% · 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 | 27.3% |
21.1%
6.2 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 36.6% · Q3 30.4% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.6% |
17.3%
4.3 pts worse
|
14.9%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 40.0% · Q3 20.0% · Q4 8.3% · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.4% |
2.3%
2.1 pts worse
|
1.0%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 2.3% · Q3 5.4% · Q4 3.4% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
3.0%
1.3 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 3.3% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.5% |
25.5%
1 pts worse
|
19.8%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 34.6% · Q3 32.5% · Q4 26.6% · 4Q avg 26.5% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.5%
1.8 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.2% |
86.8%
7.6 pts worse
|
81.7%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 79.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-25 · Fire 2023-10-25
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2022-10-12 · Fire 2022-10-12
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
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
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-13
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
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
D · 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
D · Potential for more than minimal harm
2023-10-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-08
E · Potential for more than minimal harm
2022-10-12
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-11-11
C · Minimal harm
2022-10-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-11
C · Minimal harm
2022-10-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-08
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 2025-12-17
D · Potential for more than minimal harm
2025-08-11
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 2025-08-27
F · Potential for more than minimal harm
2024-11-13
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 2024-12-04
F · Potential for more than minimal harm
2024-11-13
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-11-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-04
D · Potential for more than minimal harm
2023-11-30
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 2023-12-21
D · Potential for more than minimal harm
2023-11-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-21
F · Potential for more than minimal harm
2022-10-12
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 2022-11-12
E · Potential for more than minimal harm
2022-10-12
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-11-12
D · Potential for more than minimal harm
2022-10-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-12
D · Potential for more than minimal harm
2022-10-12
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-11-12
D · Potential for more than minimal harm
2022-10-12
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 2022-11-12
Penalties and ownership
What sits behind the stars
Ownership
Thayer, Grant
5% Or Greater Direct Ownership Interest · Individual
Novak, Annmarie
W-2 Managing Employee · Individual
Thayer, Grant
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Care & Rehab - Ladysmith 2
Ladysmith, WI
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
Cornell Health Services
Cornell, WI
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Meadowbrook At Chetek
Chetek, WI
3-star overall rating with 3-star inspections with $6,500 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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