Cycle 1
Health 2025-04-23 · Fire 2025-04-23
14 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Clintonville, WI
Greentree Health And Rehabilitation Center
2-star overall rating with 3-star inspections with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
70 Greentree Rd, Clintonville, WI
(715) 823-2194
Overall
2 / 5
CMS overall stars
Health inspections
3 / 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
50
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1984-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Weekend hours
0.00
Weekend nurse staffing
RN turnover
60%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover
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 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.2%
1.9 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 14.7% |
5.0%
9.7 pts worse
|
11.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.3% |
4.9%
0.6 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.5% |
16.6%
8.9 pts worse
|
19.6%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 19.7% |
16.7%
3 pts worse
|
16.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.7% |
21.1%
1.4 pts better
|
16.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
17.3%
2.9 pts better
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
2.3%
1 pts better
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
3.0%
1.3 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.5% |
25.5%
8 pts worse
|
19.8%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
86.8%
9.3 pts better
|
81.7%
14.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.7% |
15.0%
7.7 pts worse
|
12.0%
10.7 pts worse
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.4% |
82.2%
2.2 pts better
|
79.7%
4.7 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.4% |
22.7%
6.7 pts worse
|
23.9%
5.5 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-21 · Fire 2024-02-21
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2023-02-15 · Fire 2023-02-15
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-23
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 2025-05-02
E · Potential for more than minimal harm
2025-04-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-02
E · Potential for more than minimal harm
2025-04-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-02
F · Potential for more than minimal harm
2024-02-21
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-03-15
F · Potential for more than minimal harm
2024-02-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-15
F · Potential for more than minimal harm
2024-02-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-15
F · Potential for more than minimal harm
2024-02-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-21
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-21
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 2024-03-15
E · Potential for more than minimal harm
2024-02-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-21
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-03-15
C · Minimal harm
2024-02-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-15
F · Potential for more than minimal harm
2023-02-15
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-03-14
E · Potential for more than minimal harm
2023-02-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-14
D · Potential for more than minimal harm
2023-02-15
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 2023-05-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-09
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 2025-11-25
D · Potential for more than minimal harm
2025-10-09
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2025-11-25
G · Actual harm
2025-04-23
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 2025-05-09
E · Potential for more than minimal harm
2025-04-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-23
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 2025-05-09
D · Potential for more than minimal harm
2025-04-23
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-23
F585 · Resident Rights Deficiencies
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 2025-05-09
D · Potential for more than minimal harm
2025-04-23
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 2025-05-09
D · Potential for more than minimal harm
2025-04-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-23
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 2025-05-09
D · Potential for more than minimal harm
2025-04-23
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 2025-05-09
D · Potential for more than minimal harm
2025-04-23
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 2025-05-09
D · Potential for more than minimal harm
2025-04-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-23
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 2025-05-09
D · Potential for more than minimal harm
2024-09-11
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 2024-10-07
D · Potential for more than minimal harm
2024-09-11
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 2024-10-07
D · Potential for more than minimal harm
2024-02-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-02-25
F · Potential for more than minimal harm
2023-02-15
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 2023-03-14
D · Potential for more than minimal harm
2023-02-15
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-03-14
D · Potential for more than minimal harm
2023-02-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-02-15
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-15
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-03-07
Penalties and ownership
What sits behind the stars
Ownership
Gateway Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Elite Nurses
Operational/Managerial Control · Organization
Kamin, Shayna
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Neas, Marissa
Operational/Managerial Control · Individual
Port, Barry
Corporate Director · Individual
Prn Health Services, Inc.
Operational/Managerial Control · Organization
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3-star overall rating with 3-star inspections with $18,400 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Shawano Health Services
Shawano, WI
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Evergreen Health Services
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2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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