Cycle 1
Health 2025-02-26 · Fire 2025-02-26
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Altoona, WI
Grace Lutheran Communities - River Pines
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
206 N Willson Dr, Altoona, WI
(715) 598-7800
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
41
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2016-07-22
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
1.18
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.94
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.66
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.09
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.76
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.24
CMS adjusted RN staffing hours
Adjusted total hours
4.90
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,180
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.1
Performance 19.99% · Measure score 3.1 · Achievement 3.1 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Baseline 6.31% · Performance 8.67% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 42.86% · Performance 72.29% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.38
Baseline 4.04 hours · Performance 4.61 hours · Measure score 5.38 · Achievement 5.38 · Improvement 2.76
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.19% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 4.55% · Lower 95% interval 6.1% |
| Discharge to community | 40.2% |
50.57%
10.4 pts worse
|
Worse than the National Rate · Eligible stays 76 · Observed rate 36.84% · Lower 95% interval 31.06% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.75% |
95.27%
2.5 pts better
|
Numerator 87 · Denominator 89 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 89 |
| Discharge self-care score | 37.68% |
53.69%
16 pts worse
|
Numerator 26 · Denominator 69 |
| Discharge mobility score | 43.48% |
50.94%
7.5 pts worse
|
Numerator 30 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 7.87% |
2.29%
5.6 pts worse
|
Numerator 7 · Denominator 89 · Adjusted rate 8.33% |
| Healthcare-associated infections requiring hospitalization | 8.67% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 10.94% · Lower 95% interval 4.87% |
| Staff COVID-19 vaccination coverage | 15.32% |
8.2%
7.1 pts better
|
Numerator 17 · Denominator 111 |
| Staff flu vaccination coverage | 67.48% |
42%
25.5 pts better
|
Numerator 83 · Denominator 123 |
| Discharge function score | 46.38% |
56.45%
10.1 pts worse
|
Numerator 32 · Denominator 69 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.56% |
96.28%
0.7 pts worse
|
Numerator 43 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 47.73% |
25.2%
22.5 pts better
|
Numerator 21 · Denominator 44 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.6
0.4 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.4 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.2
1.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.7 · 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 | 97.7% |
95.0%
2.7 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.2%
0.6 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 0.0% · Q4 5.3% · 4Q avg 2.6% · 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 | 4.7% |
4.9%
0.2 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 7.1% · Q3 3.8% · Q4 4.3% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
16.6%
3 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 17.2% · Q3 11.5% · Q4 8.0% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.2% |
16.7%
6.5 pts better
|
16.7%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.3% · Q3 13.0% · 4Q avg 10.2% · 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 | 24.6% |
21.1%
3.5 pts worse
|
16.3%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.8% |
17.3%
3.5 pts better
|
14.9%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 13.8% · Q3 0.0% · Q4 16.0% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
2.3%
1.2 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
3.0%
1.7 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 2.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.8% |
25.5%
10.3 pts worse
|
19.8%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.4% · Q2 31.5% · Q3 23.6% · Q4 40.3% · 4Q avg 35.8% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.5%
0.2 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 4.3% · Q3 2.3% · Q4 5.9% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
86.8%
8.5 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.2% · Q2 91.2% · Q3 95.8% · Q4 100.0% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.6% |
15.0%
2.6 pts worse
|
12.0%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 16.1% · Expected 10.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.7% |
82.2%
5.5 pts better
|
79.7%
8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
22.7%
1.5 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 19.6% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-04 · Fire 2024-01-04
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-11-23 · Fire 2022-11-23
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-02-26
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 2025-02-26
D · Potential for more than minimal harm
2025-02-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-26
E · Potential for more than minimal harm
2024-01-04
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-01-16
E · Potential for more than minimal harm
2024-01-04
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 2024-01-16
E · Potential for more than minimal harm
2022-11-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-11-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-26
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 2025-03-14
F · Potential for more than minimal harm
2025-02-26
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 2025-03-14
D · Potential for more than minimal harm
2025-02-26
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 2025-03-14
D · Potential for more than minimal harm
2025-02-26
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 2025-03-14
D · Potential for more than minimal harm
2025-02-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-14
Penalties and ownership
What sits behind the stars
Ownership
Berg, Matthew
Operational/Managerial Control · Individual
Bohl, Amy
Operational/Managerial Control · Individual
Boyes, Alan
Corporate Director · Individual
Cohen, Jennifer
Operational/Managerial Control · Individual
Duhr, Amy
Operational/Managerial Control · Individual
Duhr, Amy
Corporate Officer · Individual
Dziekan, Dennis
Operational/Managerial Control · Individual
Felton, Connie
Corporate Director · Individual
Grothe, Arthur
Corporate Director · Individual
Larson, Jamie
Operational/Managerial Control · Individual
Larson, Jamie
Corporate Officer · Individual
Lokken, Paul
Corporate Director · Individual
Miller, Cory
Operational/Managerial Control · Individual
Palmer, Carli
Operational/Managerial Control · Individual
Peltier, Suzette
Corporate Director · Individual
Phillips, Michael
Operational/Managerial Control · Individual
Reid, Dale
Corporate Director · Individual
Schwellenbach, Dorothy
Corporate Director · Individual
Shafer, Kayla
Operational/Managerial Control · Individual
Ziehr, Ken
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Oakwood Health Services
Altoona, WI
2-star overall rating with 2-star inspections with $36,552 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Dove Healthcare - South Eau Claire
Eau Claire, WI
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Dove Healthcare - West Eau Claire
Eau Claire, WI
5-star overall rating with 3-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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