Cycle 1
Health 2025-02-19 · Fire 2025-02-19
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Wyocena, WI
Columbia Health Care Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
323 W Monroe St, Wyocena, WI
(608) 429-2181
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
85
Certified beds
Average residents
63
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-06-04
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
1.28
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.37
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.20
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.86
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.50
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.05
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.30
CMS adjusted RN staffing hours
Adjusted total hours
4.92
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
6%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,469
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.50
Composite VBP score used to determine payment impact.
Payment multiplier
1.0116
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.51
Baseline 19.36% · Performance 19.34% · Measure score 4.51 · Achievement 4.51 · Improvement 0
Healthcare-associated infections
5.55
Baseline 5.63% · Performance 6.18% · Measure score 5.55 · Achievement 5.55 · Improvement 0
Total nurse turnover
7.52
Baseline 45.45% · Performance 32.93% · Measure score 7.52 · Achievement 7.52 · Improvement 5.58
Adjusted total nurse staffing
5.01
Baseline 3.66 hours · Performance 4.50 hours · Measure score 5.01 · Achievement 5.01 · Improvement 3.47
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.19% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 7.25% · Lower 95% interval 6.53% |
| Discharge to community | 54.6% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 53.33% · Lower 95% interval 45.01% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 40 · Denominator 40 |
| Falls with major injury | 2.5% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 40 |
| Discharge self-care score | 35.9% |
53.69%
17.8 pts worse
|
Numerator 14 · Denominator 39 |
| Discharge mobility score | 41.03% |
50.94%
9.9 pts worse
|
Numerator 16 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 2 · Denominator 40 · Adjusted rate 5.17% |
| Healthcare-associated infections requiring hospitalization | 6.18% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 0% · Lower 95% interval 2.98% |
| Staff COVID-19 vaccination coverage | 10.08% |
8.2%
1.9 pts better
|
Numerator 12 · Denominator 119 |
| Staff flu vaccination coverage | 74.1% |
42%
32.1 pts better
|
Numerator 103 · Denominator 139 |
| Discharge function score | 61.54% |
56.45%
5.1 pts better
|
Numerator 24 · Denominator 39 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · 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 0.8 · Expected 1.5 · 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 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
95.0%
3.2 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.2%
About the same
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.6% · Q3 1.9% · Q4 1.8% · 4Q avg 3.2% · 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 | 3.3% |
4.9%
1.6 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 4.2% · Q4 6.4% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.4% |
16.6%
4.8 pts worse
|
19.6%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 19.6% · Q3 22.9% · Q4 23.4% · 4Q avg 21.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
16.7%
1.7 pts worse
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 21.1% · Q3 19.5% · Q4 15.0% · 4Q avg 18.4% · 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 | 11.6% |
21.1%
9.5 pts better
|
16.3%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 22.6% · Q3 11.4% · Q4 5.6% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.2% |
17.3%
1.9 pts worse
|
14.9%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 21.4% · Q3 15.9% · Q4 22.7% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
2.3%
0.2 pts better
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.0% · Q3 2.2% · Q4 1.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.0%
3 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 12.2% |
25.5%
13.3 pts better
|
19.8%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 12.4% · Q3 15.5% · Q4 13.3% · 4Q avg 12.2% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
5.5%
3.3 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.0% · Q3 1.6% · Q4 2.6% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
86.8%
10.1 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 97.8% · Q3 97.7% · Q4 96.7% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.8% |
15.0%
2.8 pts worse
|
12.0%
5.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 16.1% · Expected 10.1% · 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% · Q4 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 | 95.6% |
82.2%
13.4 pts better
|
79.7%
15.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 7.4% |
22.7%
15.3 pts better
|
23.9%
16.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 6.5% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-27 · Fire 2024-02-27
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-01-05 · Fire 2023-01-05
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-02-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-02-19
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 2025-03-27
E · Potential for more than minimal harm
2025-02-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-02-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-02-19
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-27
F · Potential for more than minimal harm
2024-02-27
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-02-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-02-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-02-27
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-27
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-03-27
F · Potential for more than minimal harm
2023-01-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-01-05
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 2023-02-05
D · Potential for more than minimal harm
2023-01-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-05
D · Potential for more than minimal harm
2023-01-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-19
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 2025-03-21
D · Potential for more than minimal harm
2023-01-05
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 2023-02-05
D · Potential for more than minimal harm
2023-01-05
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 2023-02-05
Penalties and ownership
What sits behind the stars
Ownership
County Of Columbia
5% Or Greater Direct Ownership Interest · Organization
Hardgrove, Paula
Operational/Managerial Control · Individual
Parlier, Katherine
Operational/Managerial Control · Individual
Yamriska, Amy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Randolph Health Services
Randolph, WI
1-star overall rating with 1-star inspections with $76,264 in total fines with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Dove Healthcare - Lodi
Lodi, WI
2-star overall rating with 2-star inspections with $24,183 in total fines with 2 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
#3
Columbus Health And Rehab
Columbus, WI
2-star overall rating with 2-star inspections with $151,160 in total fines with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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