Edgerton, WI
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
313 Stoughton Rd, Edgerton, WI
(608) 884-1330
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
61
Certified beds
Average residents
47
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Wisconsin Illinois Senior Housing, Inc.
Operator or chain grouping
Approved since
1971-05-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 2 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
RN hours / resident day
0.82
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.41
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.30
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.89
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.58
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
5.60
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
59%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
5,452
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9896
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.95
Baseline 17.71% · Performance 18.67% · Measure score 5.95 · Achievement 5.95 · Improvement 0
Healthcare-associated infections
5.23
Baseline 5.41% · Performance 6.27% · Measure score 5.23 · Achievement 5.23 · Improvement 0
Total nurse turnover
0
Baseline 63.04% · Performance 62.50% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.27
Baseline 3.84 hours · Performance 4.01 hours · Measure score 3.27 · Achievement 3.27 · Improvement 0.39
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.93% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 16.95% · Lower 95% interval 8.01% |
| Discharge to community | 49.1% |
50.57%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 42.5% · Lower 95% interval 36.93% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.92% |
95.27%
0.7 pts better
|
Numerator 47 · Denominator 49 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 49 |
| Discharge self-care score | 40.54% |
53.69%
13.1 pts worse
|
Numerator 15 · Denominator 37 |
| Discharge mobility score | 48.65% |
50.94%
2.3 pts worse
|
Numerator 18 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 6.12% |
2.29%
3.8 pts worse
|
Numerator 3 · Denominator 49 · Adjusted rate 5.01% |
| Healthcare-associated infections requiring hospitalization | 6.27% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 2.56% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 16.33% |
8.2%
8.1 pts better
|
Numerator 16 · Denominator 98 |
| Staff flu vaccination coverage | 44.92% |
42%
2.9 pts better
|
Numerator 53 · Denominator 118 |
| Discharge function score | 54.05% |
56.45%
2.4 pts worse
|
Numerator 20 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 56% |
25.2%
30.8 pts better
|
Numerator 14 · Denominator 25 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.7 |
1.6
2.1 pts worse
|
1.9
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 4.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.2
1 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
95.7%
1.7 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 97.4% · Q3 97.4% · Q4 97.4% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
95.0%
2.8 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| 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 2.6% · Q2 5.1% · Q3 2.6% · Q4 2.6% · 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 3.0% · Q3 0.0% · Q4 10.3% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
16.6%
2 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 15.2% · Q3 13.3% · Q4 20.0% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.8% |
16.7%
0.1 pts worse
|
16.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 16.7% · Q3 16.0% · Q4 20.8% · 4Q avg 16.8% · 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 | 17.6% |
21.1%
3.5 pts better
|
16.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
17.3%
8.8 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 12.9% · Q3 7.1% · Q4 10.3% · 4Q avg 8.5% · 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 | 2.6% |
3.0%
0.4 pts better
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.1% · Q3 0.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.6% |
25.5%
3.9 pts better
|
19.8%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 27.0% · Q3 22.5% · Q4 20.1% · 4Q avg 21.6% |
| 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 2.4% · Q2 0.0% · Q3 2.3% · Q4 8.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.2% |
86.8%
0.6 pts worse
|
81.7%
4.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.0% · Q2 89.5% · Q3 93.0% · Q4 81.7% · 4Q avg 86.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 29.0% |
15.0%
14 pts worse
|
12.0%
17 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.0% · Observed 33.3% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.3%
0.2 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 3.6% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.6% |
82.2%
12.6 pts worse
|
79.7%
10.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
22.7%
2.6 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 21.2% · Expected 25.2% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-04-24
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 2025-04-24
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-08
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-24
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-24
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-24
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-04-24
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-24
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-17
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-17
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-05-17
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-17
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-17
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-17
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 2024-05-17
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-17
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-17
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-25
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-05-17
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-05-17
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-09-25
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-17
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-02-28
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-17
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-02-24
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-02-28
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 2023-02-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-17
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-13
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-15
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-28
Inspection history
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-16
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-24
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-24
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-24
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-24
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-04-24
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-24
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-04-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-24
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 2025-04-24
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-24
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-24
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-06-12
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-12
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-06-07
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-07
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-07
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-22
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-22
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-22
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-22
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-04-22
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-22
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-22
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-17
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-03-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-01
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-01
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-03-01
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
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-03-01
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-03-01
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-23
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-01
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-01
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-03-01
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-03-01
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-03-01
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-01
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-01
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 2023-03-01
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-03-01
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 2023-03-01
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-03-01
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-01
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-03-01
Penalties and ownership
W-2 Managing Employee · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
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