Cycle 1
Health 2025-01-29 · Fire 2025-01-29
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Chippewa Falls, WI
Chippewa Manor Nursing And Rehabilitation
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
222 Chapman Rd, Chippewa Falls, WI
(715) 723-4437
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
43
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-02-09
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
1.46
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.22
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.92
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.59
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.93
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.65
CMS adjusted RN staffing hours
Adjusted total hours
5.18
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
8%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
811
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.44
Composite VBP score used to determine payment impact.
Payment multiplier
1.0182
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.93
Baseline 19.12% · Performance 18.22% · Measure score 6.93 · Achievement 6.93 · Improvement 3.81
Healthcare-associated infections
5.24
Baseline 7.11% · Performance 6.27% · Measure score 5.24 · Achievement 5.24 · Improvement 3.48
Total nurse turnover
7.93
Baseline 52.27% · Performance 31.25% · Measure score 7.93 · Achievement 7.93 · Improvement 7.17
Adjusted total nurse staffing
5.27
Baseline 4.47 hours · Performance 4.58 hours · Measure score 5.27 · Achievement 5.27 · Improvement 0.32
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.26% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 164 · Observed rate 7.93% · Lower 95% interval 7.65% |
| Discharge to community | 49.4% |
50.57%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 159 · Observed rate 49.06% · Lower 95% interval 43.53% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 87.96% |
95.27%
7.3 pts worse
|
Numerator 95 · Denominator 108 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 108 |
| Discharge self-care score | 40.86% |
53.69%
12.8 pts worse
|
Numerator 38 · Denominator 93 |
| Discharge mobility score | 49.46% |
50.94%
1.5 pts worse
|
Numerator 46 · Denominator 93 |
| Pressure ulcers or injuries, new or worsened | 1.85% |
2.29%
0.4 pts better
|
Numerator 2 · Denominator 108 · Adjusted rate 2.59% |
| Healthcare-associated infections requiring hospitalization | 6.27% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 3.6% · Lower 95% interval 4.02% |
| Staff COVID-19 vaccination coverage | 15.6% |
8.2%
7.4 pts better
|
Numerator 22 · Denominator 141 |
| Staff flu vaccination coverage | 38.38% |
42%
3.6 pts worse
|
Numerator 38 · Denominator 99 |
| Discharge function score | 52.69% |
56.45%
3.8 pts worse
|
Numerator 49 · Denominator 93 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 79 · Denominator 79 |
| Resident COVID-19 vaccinations up to date | 35.85% |
25.2%
10.7 pts better
|
Numerator 19 · Denominator 53 |
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 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.2
1.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
95.7%
1.3 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 95.8% · Q3 96.9% · Q4 100.0% · 4Q avg 97.0% |
| 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 | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 3.1% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
5.0%
4 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
4.9%
3 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 10.0% · Q3 14.3% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
16.6%
10.7 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 25.0% · Q3 36.4% · 4Q avg 27.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.7% |
16.7%
10 pts better
|
16.7%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.7% · 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 | 21.4% |
21.1%
0.3 pts worse
|
16.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.8% |
17.3%
5.5 pts better
|
14.9%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.6% |
2.3%
2.3 pts worse
|
1.0%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.9% · Q3 5.8% · Q4 2.9% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.1% |
3.0%
2.1 pts worse
|
1.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 4.2% · Q3 6.5% · Q4 0.0% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.0% |
25.5%
3.5 pts worse
|
19.8%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 22.0% · Q3 33.5% · Q4 17.7% · 4Q avg 29.0% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.5%
2.2 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.8% · Q4 5.2% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
86.8%
5.5 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 90.4% · Q3 94.4% · Q4 90.2% · 4Q avg 92.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.8% |
15.0%
8.2 pts better
|
12.0%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 5.7% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.3%
0.3 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.3% · Q3 1.5% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.6% |
82.2%
4.6 pts worse
|
79.7%
2.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
22.7%
3.3 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 14.8% · Expected 18.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-08 · Fire 2023-11-08
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-10-12 · Fire 2022-10-12
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-29
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-29
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-02-21
D · Potential for more than minimal harm
2023-11-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Not marked corrected
D · Potential for more than minimal harm
2023-11-08
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Not marked corrected
D · Potential for more than minimal harm
2022-10-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-01
D · Potential for more than minimal harm
2022-10-12
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-11-01
D · Potential for more than minimal harm
2022-10-12
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 2022-11-01
D · Potential for more than minimal harm
2022-10-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-02-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-29
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-29
F625 · Resident Rights Deficiencies
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 2025-02-21
D · Potential for more than minimal harm
2025-01-29
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 2025-02-21
D · Potential for more than minimal harm
2023-11-08
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-12-07
C · Minimal harm
2023-11-08
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-12-07
C · Minimal harm
2023-11-08
F625 · Resident Rights Deficiencies
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 2023-12-07
C · Minimal harm
2023-11-08
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-12-07
Penalties and ownership
What sits behind the stars
Ownership
Chippewa Manor Corporation
5% Or Greater Direct Ownership Interest · Organization
Rubel, Darrell
5% Or Greater Indirect Ownership Interest · Individual
Nicastro, Scott
Corporate Director · Individual
Nicastro, Scott
Corporate Officer · Individual
Rubel, Darrell
Corporate Officer · Individual
Thiess, Jeffrey
Corporate Director · Individual
Thiess, Jeffrey
Corporate Officer · Individual
Thorsness, Brandon
Corporate Officer · Individual
Thorsness, Brandon
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Wi Veterans Home At Chippewa Falls
Chippewa Falls, WI
5-star overall rating with 4-star inspections with 5 recent health deficiencies
#2
Dove Healthcare - Regional Vent Center
Chippewa Falls, WI
3-star overall rating with 3-star inspections with $66,888 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Oakwood Health Services
Altoona, WI
2-star overall rating with 2-star inspections with $36,552 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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