Cycle 1
Health 2024-12-11 · Fire 2024-12-11
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Glenwood City, WI
Glenhaven
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
612 E Oak St, Glenwood City, WI
(715) 265-4555
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
44
Certified beds
Average residents
24
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-10-01
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
1.29
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.44
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.08
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.81
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.27
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.00
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.42
CMS adjusted RN staffing hours
Adjusted total hours
5.30
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
63%
Annual nurse turnover · state 48% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.68% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 6.94% |
| Discharge to community | 51.03% |
50.57%
0.5 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 50% · Lower 95% interval 32.92% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 22 · Denominator 22 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 22 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 22 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 27.66% |
8.2%
19.5 pts better
|
Numerator 13 · Denominator 47 |
| Staff flu vaccination coverage | 40.32% |
42%
1.7 pts worse
|
Numerator 25 · Denominator 62 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · 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 · 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 | 4.1% |
3.2%
0.9 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.1% |
5.0%
3.1 pts worse
|
11.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.1% |
| Percentage of long-stay residents who lose too much weight | 1.5% |
4.9%
3.4 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.9% |
16.6%
6.3 pts worse
|
19.6%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.9% |
16.7%
15.2 pts worse
|
16.7%
15.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.9% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.4% |
21.1%
0.3 pts worse
|
16.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
17.3%
3 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.5% |
2.3%
1.2 pts worse
|
1.0%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
3.0%
1.6 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
25.5%
7.9 pts better
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.6% |
| Percentage of long-stay residents with pressure ulcers | 11.5% |
5.5%
6 pts worse
|
5.1%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
86.8%
7.6 pts better
|
81.7%
12.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 90.5% · Q4 100.0% · 4Q avg 94.4% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-10-20 · Fire 2022-10-20
9 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-11
F · Potential for more than minimal harm
2024-12-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-11
D · Potential for more than minimal harm
2024-12-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-11
C · Minimal harm
2024-12-11
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 2025-02-11
D · Potential for more than minimal harm
2023-11-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-20
F · Potential for more than minimal harm
2022-10-20
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-11-21
F · Potential for more than minimal harm
2022-10-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-21
F · Potential for more than minimal harm
2022-10-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-30
C · Minimal harm
2022-10-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-11-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-08-25
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 2025-09-25
D · Potential for more than minimal harm
2025-04-02
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 2025-05-02
D · Potential for more than minimal harm
2025-04-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-02
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 2025-05-02
F · Potential for more than minimal harm
2024-12-11
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 2025-01-11
F · Potential for more than minimal harm
2024-12-11
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-11
D · Potential for more than minimal harm
2024-12-11
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 2025-01-11
D · Potential for more than minimal harm
2024-12-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-11
D · Potential for more than minimal harm
2024-12-11
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 2025-01-11
D · Potential for more than minimal harm
2024-12-11
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 2025-01-11
D · Potential for more than minimal harm
2024-12-11
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-01-11
D · Potential for more than minimal harm
2024-12-11
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 2025-01-11
F · Potential for more than minimal harm
2023-11-30
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 2023-12-30
F · Potential for more than minimal harm
2023-11-30
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 2023-12-30
F · Potential for more than minimal harm
2023-11-30
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-11-30
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-30
C · Minimal harm
2023-11-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-03-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-03-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-05
F · Potential for more than minimal harm
2022-10-20
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 2022-11-18
E · Potential for more than minimal harm
2022-10-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-20
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 2022-11-18
D · Potential for more than minimal harm
2022-10-20
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 2022-11-18
D · Potential for more than minimal harm
2022-10-20
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 2022-11-18
D · Potential for more than minimal harm
2022-10-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-11-18
B · Minimal harm
2022-10-20
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-11-18
Penalties and ownership
What sits behind the stars
Ownership
Field, Thomas
Operational/Managerial Control · Individual
Glenhaven, Inc.
Operational/Managerial Control · Organization
Glenhaven, Inc.
5% Or Greater Mortgage Interest · Organization
Larson, Kevin
Operational/Managerial Control · Individual
Larson, Kevin
Corporate Director · Individual
Mccutchin, John
Operational/Managerial Control · Individual
Mccutchin, John
Corporate Director · Individual
Mccutchin, John
Corporate Officer · Individual
Nelson, Lesley
Operational/Managerial Control · Individual
Nelson, Lesley
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Park View Home
Woodville, WI
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Baldwin Care Center
Baldwin, WI
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Hammond Health Services
Hammond, WI
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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