Cycle 1
Health 2025-09-04 · Fire 2025-09-04
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Verona, WI
Four Winds Manor
1-star overall rating with 2-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
303 S Jefferson St, Verona, WI
(608) 845-6465
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
44
Certified beds
Average residents
34
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-07-01
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
0.85
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.84
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.51
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
0.24
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
100%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,785
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.68
Baseline 18.92% · Performance 21.12% · Measure score 0.68 · Achievement 0.68 · Improvement 0
Healthcare-associated infections
4.54
Baseline 5.66% · Performance 6.48% · Measure score 4.54 · Achievement 4.54 · Improvement 0
Total nurse turnover
0
Baseline 58.00% · Performance 64.58% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.06
Baseline 4.49 hours · Performance 4.52 hours · Measure score 5.06 · Achievement 5.06 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.2% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 103 · Observed rate 6.8% · Lower 95% interval 6.91% |
| Discharge to community | 63.08% |
50.57%
12.5 pts better
|
Better than the National Rate · Eligible stays 107 · Observed rate 61.68% · Lower 95% interval 53.99% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 70 · Denominator 70 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 70 |
| Discharge self-care score | 55.77% |
53.69%
2.1 pts better
|
Numerator 29 · Denominator 52 |
| Discharge mobility score | 63.46% |
50.94%
12.5 pts better
|
Numerator 33 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 2.86% |
2.29%
0.6 pts worse
|
Numerator 2 · Denominator 70 · Adjusted rate 2.62% |
| Healthcare-associated infections requiring hospitalization | 6.48% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 3.64% · Lower 95% interval 3.54% |
| Staff COVID-19 vaccination coverage | 15.04% |
8.2%
6.8 pts better
|
Numerator 17 · Denominator 113 |
| Staff flu vaccination coverage | 45.65% |
42%
3.6 pts better
|
Numerator 63 · Denominator 138 |
| Discharge function score | 53.85% |
56.45%
2.6 pts worse
|
Numerator 28 · Denominator 52 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.06% |
96.28%
0.8 pts better
|
Numerator 33 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 71.88% |
25.2%
46.7 pts better
|
Numerator 23 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
1.6
1.5 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.2
0.2 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.3 · 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 | 97.0% |
95.0%
2 pts better
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.2%
1.4 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
5.0%
2.8 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.2% · Q4 0.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
4.9%
2.7 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 4.5% · Q4 5.0% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.4% |
16.6%
9.2 pts better
|
19.6%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 8.7% · Q4 5.0% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
16.7%
7.6 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · 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 need for help with daily activities has increased | 15.7% |
17.3%
1.6 pts better
|
14.9%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 19.0% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 13.7% |
2.3%
11.4 pts worse
|
1.0%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 10.8% · Q3 20.1% · Q4 15.4% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
3.0%
0.2 pts better
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.7% · Q3 0.0% · Q4 3.6% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
25.5%
5.9 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 19.4% · Q3 25.9% · Q4 22.9% · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
5.5%
1.5 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 3.6% · Q3 2.8% · Q4 0.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
86.8%
7.4 pts better
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.8% · Q2 91.5% · Q3 95.3% · Q4 95.1% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
15.0%
2.7 pts better
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 11.1% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.3%
0.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.5% |
82.2%
5.3 pts better
|
79.7%
7.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
22.7%
2.6 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 22.2% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-06 · Fire 2024-08-06
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
12 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-04-19 · Fire 2023-04-19
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-04
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-09-29
F · Potential for more than minimal harm
2025-09-04
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-09-22
E · Potential for more than minimal harm
2025-09-04
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-09-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-29
E · Potential for more than minimal harm
2025-09-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-09-04
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-09-04
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-09-22
F · Potential for more than minimal harm
2024-08-06
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-08-06
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-02
F · Potential for more than minimal harm
2024-08-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-11
F · Potential for more than minimal harm
2024-08-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-08-06
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-08-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-08-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-08-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-08-06
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-08-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-08-06
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-08-23
F · Potential for more than minimal harm
2023-04-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-08
F · Potential for more than minimal harm
2023-04-19
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2023-05-19
E · Potential for more than minimal harm
2023-04-19
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-04-19
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-04-19
K223 · Egress Deficiencies
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 2023-05-03
D · Potential for more than minimal harm
2023-04-19
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-04-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-11
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 2025-12-12
D · Potential for more than minimal harm
2025-12-11
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 2025-12-12
G · Actual harm
2025-09-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-29
E · Potential for more than minimal harm
2025-09-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-09-04
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-09-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-09-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-09-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-09-04
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-09-04
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-01-24
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-24
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-08-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-26
F · Potential for more than minimal harm
2024-08-06
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-08-06
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 2024-09-06
E · Potential for more than minimal harm
2024-08-06
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-08-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-08-06
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 2024-08-22
D · Potential for more than minimal harm
2024-08-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-08-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-08-06
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-08-06
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-08-07
D · Potential for more than minimal harm
2024-04-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-17
G · Actual harm
2023-08-22
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 2023-09-27
D · Potential for more than minimal harm
2023-06-20
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 2023-07-06
D · Potential for more than minimal harm
2023-04-19
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 2023-05-12
D · Potential for more than minimal harm
2023-04-19
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 2023-05-12
D · Potential for more than minimal harm
2023-04-19
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-05-12
Penalties and ownership
What sits behind the stars
$0
2023-08-22
Payment Denial
Payment Denial · denial start 2023-09-16 · 11 days
11 day denial
Ownership
Howard, Mary
5% Or Greater Direct Ownership Interest · Individual
Howard, Mary
Operational/Managerial Control · Individual
Howard, Mary
Corporate Officer · Individual
Kellogg, Shari
Operational/Managerial Control · Individual
Lubsen, Julia
Operational/Managerial Control · Individual
Riedmaier, Rose
Operational/Managerial Control · Individual
State Bank Of Cross Plains
5% Or Greater Mortgage Interest · Organization
Wegner Cpas
Operational/Managerial Control · Organization
Wipfli Llp
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Badger Prairie Hcc
Verona, WI
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Complete Care at Maple Grove LLC
Madison, WI
1-star overall rating with 1-star inspections with $95,303 in total fines with 17 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Hebron Oaks
Madison, WI
3-star overall rating with 3-star inspections with $22,925 in total fines with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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