Cycle 1
Health 2025-05-21 · Fire 2025-05-21
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Colby, WI
Colonial Health Services
2-star overall rating with 2-star inspections with $34,140 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
702 W Dolf St, Colby, WI
(715) 223-2352
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
60
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Twin Rivers Health & Rehabilitation
Operator or chain grouping
Approved since
1984-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 4 overall / 4 health / 3 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
0.74
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.52
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
0.80
CMS adjusted RN staffing hours
Adjusted total hours
3.82
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
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
9,166
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.53% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Baseline 5.90% · Performance 7.82% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.50
Baseline 41.86% · Performance 37.10% · Measure score 6.50 · Achievement 6.50 · Improvement 2.3
Adjusted total nurse staffing
3.33
Baseline 3.50 hours · Performance 4.03 hours · Measure score 3.33 · Achievement 3.33 · Improvement 1.79
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.5% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 12.5% · Lower 95% interval 7.83% |
| Discharge to community | 43.47% |
50.57%
7.1 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 36.54% · Lower 95% interval 30.97% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.65% |
95.27%
0.4 pts better
|
Numerator 22 · Denominator 23 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 23 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 14 · Denominator 21 |
| Discharge mobility score | 38.1% |
50.94%
12.8 pts worse
|
Numerator 8 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 23 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.82% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 11.43% · Lower 95% interval 4.34% |
| Staff COVID-19 vaccination coverage | 2.25% |
8.2%
5.9 pts worse
|
Numerator 2 · Denominator 89 |
| Staff flu vaccination coverage | 34.86% |
42%
7.1 pts worse
|
Numerator 38 · Denominator 109 |
| Discharge function score | 61.9% |
56.45%
5.4 pts better
|
Numerator 13 · Denominator 21 |
| 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 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.5 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.2
1.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.0 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.8% |
95.7%
7.9 pts worse
|
93.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 84.5% · Q3 80.0% · Q4 88.2% · 4Q avg 87.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
95.0%
1.7 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.2%
2.4 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.4% · Q3 9.1% · Q4 5.9% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
5.0%
2.4 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
4.9%
0.6 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.0% · Q3 6.1% · Q4 6.5% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.8% |
16.6%
6.8 pts better
|
19.6%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 11.5% · Q3 4.0% · Q4 8.2% · 4Q avg 9.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.1% |
16.7%
12.4 pts worse
|
16.7%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 30.8% · Q3 25.7% · Q4 30.6% · 4Q avg 29.1% · 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 | 30.7% |
21.1%
9.6 pts worse
|
16.3%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 30.2% · Q4 19.8% · 4Q avg 30.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.0% |
17.3%
8.7 pts worse
|
14.9%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 29.2% · Q3 21.3% · Q4 29.8% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.3% |
3.0%
4.3 pts worse
|
1.7%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 1.8% · Q3 7.4% · Q4 12.5% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.0% |
25.5%
2.5 pts better
|
19.8%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 22.8% · Q3 15.2% · Q4 25.2% · 4Q avg 23.0% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
5.5%
2.5 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 8.3% · Q3 10.8% · Q4 6.6% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.6% |
86.8%
7.2 pts worse
|
81.7%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 83.1% · Q3 74.6% · Q4 61.8% · 4Q avg 79.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
15.0%
15 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.9% |
82.2%
5.7 pts better
|
79.7%
8.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.8% |
22.7%
6.1 pts worse
|
23.9%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.8% · Observed 27.8% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-14 · Fire 2024-03-14
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-02-16 · Fire 2023-02-16
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-21
D · Potential for more than minimal harm
2025-05-21
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 2025-06-21
C · Minimal harm
2025-05-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-21
C · Minimal harm
2025-05-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-21
D · Potential for more than minimal harm
2024-03-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-03
C · Minimal harm
2024-03-14
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-04-03
F · Potential for more than minimal harm
2023-02-16
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-02-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-13
E · Potential for more than minimal harm
2023-02-16
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 2023-03-13
D · Potential for more than minimal harm
2023-02-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-13
Inspection history
Recent health citations
J · Immediate jeopardy
2025-08-19
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.
Corrected 2025-09-15
J · Immediate jeopardy
2025-08-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-05-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-21
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 2025-06-13
D · Potential for more than minimal harm
2025-05-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-13
D · Potential for more than minimal harm
2024-10-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-03-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-03
D · Potential for more than minimal harm
2023-02-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-02-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-02-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-10
Penalties and ownership
What sits behind the stars
$34,140
2025-08-19
Fine
Fine · fine $34,140
Fine
Ownership
Baumann, Troy
Operational/Managerial Control · Individual
Belongia, Christina
Operational/Managerial Control · Individual
Cibc Bank Usa
Operational/Managerial Control · Organization
Cibc Bank Usa
5% Or Greater Security Interest · Organization
Cibc Bank Usa
5% Or Greater Mortgage Interest · Organization
Cliftonlarsonallen Llp
Operational/Managerial Control · Organization
Continuum Therapy Partners
Operational/Managerial Control · Organization
Decker, Dana
Operational/Managerial Control · Individual
Gee, Darren
Operational/Managerial Control · Individual
Greer, Lauren
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Operational/Managerial Control · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
Patzer, Colleen
Operational/Managerial Control · Individual
Purtell, Brian
Operational/Managerial Control · Individual
Umland, Michael
Operational/Managerial Control · Individual
Wipfli Llp
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Abbotsford Health Care Center
Abbotsford, WI
2-star overall rating with 2-star inspections with $15,939 in total fines with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Clark County Rehabilitation & Living Center
Owen, WI
2-star overall rating with 2-star inspections with 19 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Aspirus Care & Rehab-Medford
Medford, WI
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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