Cycle 1
Health 2025-03-12 · Fire 2025-03-12
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Columbus, WI
Columbus Health And Rehab
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
825 Western Ave, Columbus, WI
(920) 623-2520
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Health Communities
Operator or chain grouping
Approved since
1989-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
40 facilities
Chain averages 3 overall / 3 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
0.95
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.48
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.01
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.47
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,234
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9859
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.74
Baseline 21.93% · Performance 19.36% · Measure score 4.74 · Achievement 4.47 · Improvement 4.74
Healthcare-associated infections
0
Baseline 6.86% · Performance 7.98% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.32
Baseline 42.31% · Performance 37.84% · Measure score 6.32 · Achievement 6.32 · Improvement 2.06
Adjusted total nurse staffing
1.07
Performance 3.38 hours · Measure score 1.07 · Achievement 1.07 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.87% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 15.52% · Lower 95% interval 7.32% |
| Discharge to community | 46.33% |
50.57%
4.2 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 40% · Lower 95% interval 33.74% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 54 · Denominator 54 |
| Falls with major injury | 1.85% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 54 |
| Discharge self-care score | 65.22% |
53.69%
11.5 pts better
|
Numerator 30 · Denominator 46 |
| Discharge mobility score | 60.87% |
50.94%
9.9 pts better
|
Numerator 28 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 54 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.98% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 10.81% · Lower 95% interval 4.36% |
| Staff COVID-19 vaccination coverage | 12.86% |
8.2%
4.7 pts better
|
Numerator 9 · Denominator 70 |
| Staff flu vaccination coverage | 53.26% |
42%
11.3 pts better
|
Numerator 49 · Denominator 92 |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 24 · Denominator 46 |
| 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 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 45.16% |
25.2%
20 pts better
|
Numerator 14 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 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 | 9.3% |
3.2%
6.1 pts worse
|
3.3%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 10.3% · Q3 10.3% · Q4 8.0% · 4Q avg 9.3% · 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 | 10.8% |
4.9%
5.9 pts worse
|
5.4%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 13.6% · Q3 13.6% · 4Q avg 10.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.7% |
16.6%
11.9 pts better
|
19.6%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.3% · Q3 4.3% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.8% |
16.7%
7.9 pts better
|
16.7%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.8% · 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 | 17.1% |
21.1%
4 pts better
|
16.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
17.3%
12.3 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 0.0% · Q3 0.0% · 4Q avg 5.0% · 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 | 4.7% |
3.0%
1.7 pts worse
|
1.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 6.9% · Q4 8.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.2% |
25.5%
10.3 pts better
|
19.8%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 23.1% · Q3 13.6% · Q4 16.5% · 4Q avg 15.2% |
| Percentage of long-stay residents with pressure ulcers | 9.0% |
5.5%
3.5 pts worse
|
5.1%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.0% · Q3 16.1% · Q4 9.9% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.8% |
86.8%
8 pts better
|
81.7%
13.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 95.5% · Q3 95.0% · Q4 94.7% · 4Q avg 94.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
15.0%
0.7 pts better
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 13.3% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.3%
1.1 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.1% · Q3 2.6% · Q4 2.7% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.3% |
82.2%
1.9 pts worse
|
79.7%
0.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
22.7%
2.2 pts worse
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 23.3% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-02-01 · Fire 2023-02-01
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-12
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 2025-04-02
E · Potential for more than minimal harm
2025-03-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-02
E · Potential for more than minimal harm
2025-03-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-02
E · Potential for more than minimal harm
2025-03-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-02
E · Potential for more than minimal harm
2025-03-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-12
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-02
F · Potential for more than minimal harm
2024-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-07
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-07
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-03-07
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 2024-04-05
E · Potential for more than minimal harm
2024-03-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-03-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-05
F · Potential for more than minimal harm
2023-02-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-11
F · Potential for more than minimal harm
2023-02-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-18
E · Potential for more than minimal harm
2023-02-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-18
E · Potential for more than minimal harm
2023-02-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-18
D · Potential for more than minimal harm
2023-02-01
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-03-18
D · Potential for more than minimal harm
2023-02-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-18
D · Potential for more than minimal harm
2023-02-01
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-03-18
Inspection history
Recent health citations
G · Actual harm
2025-03-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-02
F · Potential for more than minimal harm
2025-03-12
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 2025-04-02
F · Potential for more than minimal harm
2025-03-12
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-04-02
F · Potential for more than minimal harm
2025-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-12
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 2025-04-02
D · Potential for more than minimal harm
2025-03-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-12
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 2025-04-02
D · Potential for more than minimal harm
2025-03-12
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-12
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-04-02
F · Potential for more than minimal harm
2024-03-07
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 2024-04-05
D · Potential for more than minimal harm
2024-03-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-07
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 2024-04-05
F · Potential for more than minimal harm
2023-02-01
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 2023-03-01
Penalties and ownership
What sits behind the stars
$151,160
2025-03-12
Fine
Fine · fine $151,160
Fine
Ownership
Wisconsin Operator LLC
5% Or Greater Direct Ownership Interest · Organization
Barnes, Michelle
Operational/Managerial Control · Individual
Barres, LLC
5% Or Greater Indirect Ownership Interest · Organization
Crino, Bryan
5% Or Greater Indirect Ownership Interest · Individual
Feuer, Scott
5% Or Greater Indirect Ownership Interest · Individual
Kraus, Bruce
Corporate Director · Individual
Lindeman, Stuart
5% Or Greater Indirect Ownership Interest · Individual
Mission Health Communities, LLC
Operational/Managerial Control · Organization
Passero, Joseph
5% Or Greater Indirect Ownership Interest · Individual
Reierson, Brenda
Corporate Director · Individual
T And C Capital Assets, LLC
5% Or Greater Indirect Ownership Interest · Organization
Windward Health Partners LLC
5% Or Greater Indirect Ownership Interest · Organization
Wisconsin Operator LLC
Operational/Managerial Control · Organization
Nearby options
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Beaver Dam, WI
1-star overall rating with 1-star inspections with abuse icon flag with $144,764 in total fines with 21 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Hillside Manor
Beaver Dam, WI
3-star overall rating with 2-star inspections with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
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
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