Cycle 1
Health 2025-08-13 · Fire 2025-08-13
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Port Edwards, WI
Edgewater Haven Nursing Home
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1351 Wisconsin River Dr, Port Edwards, WI
(715) 885-8300
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
45
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
1.19
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.40
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.80
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.89
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.34
CMS adjusted RN staffing hours
Adjusted total hours
4.93
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,394
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9977
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.40
Baseline 21.01% · Performance 20.78% · Measure score 1.40 · Achievement 1.40 · Improvement 0.06
Healthcare-associated infections
0
Baseline 6.71% · Performance 7.92% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 31.67% · Performance 17.02% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
6.42
Baseline 4.48 hours · Performance 4.91 hours · Measure score 6.42 · Achievement 6.42 · Improvement 2.75
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.09% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 5.88% · Lower 95% interval 6.79% |
| Discharge to community | 58.35% |
50.57%
7.8 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 63.29% · Lower 95% interval 49.97% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 37 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | 72% |
53.69%
18.3 pts better
|
Numerator 18 · Denominator 25 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 10 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 5.41% |
2.29%
3.1 pts worse
|
Numerator 2 · Denominator 37 · Adjusted rate 5.22% |
| Healthcare-associated infections requiring hospitalization | 7.92% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 8.57% · Lower 95% interval 4.09% |
| Staff COVID-19 vaccination coverage | 24.76% |
8.2%
16.6 pts better
|
Numerator 26 · Denominator 105 |
| Staff flu vaccination coverage | 96.36% |
42%
54.4 pts better
|
Numerator 159 · Denominator 165 |
| Discharge function score | 56% |
56.45%
0.5 pts worse
|
Numerator 14 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
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 | 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 | 10.9% |
3.2%
7.7 pts worse
|
3.3%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 17.6% · Q3 9.7% · Q4 2.9% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
5.0%
4.2 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
4.9%
0.8 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 3.7% · Q4 11.1% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.9% |
16.6%
1.7 pts better
|
19.6%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 13.3% · Q3 18.5% · Q4 22.2% · 4Q avg 14.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
16.7%
10.5 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 12.5% · Q4 12.5% · 4Q avg 6.2% · 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 | 23.6% |
21.1%
2.5 pts worse
|
16.3%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.5% |
17.3%
8.2 pts worse
|
14.9%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 16.7% · Q3 47.8% · Q4 31.8% · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
2.3%
0.1 pts better
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 3.3% · Q4 2.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
3.0%
1.5 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 3.2% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.9% |
25.5%
3.6 pts better
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 16.1% · Q3 19.2% · Q4 27.6% · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
5.5%
3.1 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.9% · Q3 0.0% · Q4 5.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
86.8%
12.7 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.2% |
15.0%
6.2 pts worse
|
12.0%
9.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 17.5% · Expected 9.2% · 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 3.0% · Q3 2.4% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
82.2%
17.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| 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 15.0% · Expected 17.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-26 · Fire 2024-06-26
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-06-07 · Fire 2023-06-07
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-13
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 2025-09-04
F · Potential for more than minimal harm
2025-08-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-08-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-15
F · Potential for more than minimal harm
2024-06-26
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 2024-08-05
F · Potential for more than minimal harm
2024-06-26
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-06-27
F · Potential for more than minimal harm
2024-06-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-27
F · Potential for more than minimal harm
2024-06-26
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-07-26
F · Potential for more than minimal harm
2024-06-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-27
E · Potential for more than minimal harm
2024-06-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-06-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-14
E · Potential for more than minimal harm
2024-06-26
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-06-27
E · Potential for more than minimal harm
2024-06-26
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-07-05
E · Potential for more than minimal harm
2023-06-07
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-06-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-06-07
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 2023-07-06
D · Potential for more than minimal harm
2023-06-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-13
F761 · Pharmacy Service Deficiencies
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 2025-09-12
D · Potential for more than minimal harm
2025-08-13
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 2025-09-12
D · Potential for more than minimal harm
2025-08-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-12
F · Potential for more than minimal harm
2024-06-26
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-07-26
F · Potential for more than minimal harm
2024-06-26
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 2024-07-26
D · Potential for more than minimal harm
2024-06-26
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 2024-07-26
D · Potential for more than minimal harm
2024-06-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-26
Penalties and ownership
What sits behind the stars
Ownership
Cieslewicz, Justin
Corporate Director · Individual
Cieslewicz, Justin
Corporate Officer · Individual
Cieslewicz, Justin
W-2 Managing Employee · Individual
Gehrt, Heather
Corporate Officer · Individual
Gehrt, Heather
W-2 Managing Employee · Individual
Ramnanan, Keshni
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Wisconsin Rapids Health Services
Wisconsin Rapids, WI
1-star overall rating with 1-star inspections with $99,626 in total fines with 20 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Edenbrook Of Wisconsin Rapids
Wisconsin Rapids, WI
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Stevens Point Health Services
Stevens Point, WI
1-star overall rating with 2-star inspections with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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