Cycle 1
Health 2024-10-03 · Fire 2024-10-03
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Spring Green, WI
Greenway Manor
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
501 S Winsted St, Spring Green, WI
(608) 588-2586
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
49
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-01-01
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
0.82
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.37
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.92
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.19
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
0.71
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
4.33
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,358
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9979
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.11
Baseline 48.28% · Performance 46.88% · Measure score 4.11 · Achievement 4.11 · Improvement 0.10
Adjusted total nurse staffing
4.84
Baseline 3.98 hours · Performance 4.45 hours · Measure score 4.84 · Achievement 4.84 · Improvement 2.12
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 36 · Observed rate 5.56% · Lower 95% interval 7.07% |
| Discharge to community | 47.75% |
50.57%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 42.31% · Lower 95% interval 33.58% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 30 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 26.09% |
53.69%
27.6 pts worse
|
Numerator 6 · Denominator 23 |
| Discharge mobility score | 17.39% |
50.94%
33.5 pts worse
|
Numerator 4 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 30 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 11.17% |
8.2%
3 pts better
|
Numerator 20 · Denominator 179 |
| Staff flu vaccination coverage | 58.78% |
42%
16.8 pts better
|
Numerator 77 · Denominator 131 |
| Discharge function score | 26.09% |
56.45%
30.4 pts worse
|
Numerator 6 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.2
0.6 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
95.7%
2.7 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 97.8% · Q3 100.0% · Q4 100.0% · 4Q avg 98.4% |
| 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 | 5.3% |
3.2%
2.1 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.4% · Q3 6.1% · Q4 6.4% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.8% |
5.0%
4.8 pts worse
|
11.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 5.0% · Q3 13.6% · Q4 11.1% · 4Q avg 9.8% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
4.9%
2.7 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.5% |
16.6%
4.9 pts worse
|
19.6%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 20.6% · Q3 23.1% · Q4 19.4% · 4Q avg 21.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.4% |
16.7%
3.7 pts worse
|
16.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 16.0% · Q3 18.5% · Q4 16.7% · 4Q avg 20.4% · 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 | 23.5% |
21.1%
2.4 pts worse
|
16.3%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 42.6% · Q3 16.5% · Q4 12.8% · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.6% |
17.3%
6.3 pts worse
|
14.9%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 21.2% · Q3 21.1% · Q4 25.0% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
2.3%
0.7 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.4% · Q3 1.9% · Q4 2.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.0% |
3.0%
2 pts worse
|
1.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.8% · Q3 2.1% · Q4 11.4% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.8% |
25.5%
2.3 pts worse
|
19.8%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 35.4% · Q3 22.1% · Q4 29.4% · 4Q avg 27.8% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
5.5%
3.7 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.5% |
86.8%
3.7 pts better
|
81.7%
8.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.0% · Q2 90.9% · 4Q avg 90.5% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 8.8% |
1.3%
7.5 pts worse
|
1.6%
7.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.9% |
82.2%
8.7 pts better
|
79.7%
11.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-07 · Fire 2023-09-07
0 health deficiencies
No concentrated health issue counts in this cycle.
10 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2022-06-29 · Fire 2022-06-29
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-10-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-10-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-10-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-17
F · Potential for more than minimal harm
2023-09-07
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-09-21
F · Potential for more than minimal harm
2023-09-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-21
E · Potential for more than minimal harm
2023-09-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-07
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-09-21
E · Potential for more than minimal harm
2023-09-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-09-07
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-09-07
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-09-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-09-07
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-09-21
F · Potential for more than minimal harm
2022-06-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-07-03
F · Potential for more than minimal harm
2022-06-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-12
E · Potential for more than minimal harm
2022-06-29
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-07-19
E · Potential for more than minimal harm
2022-06-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-07-20
E · Potential for more than minimal harm
2022-06-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-07-08
D · Potential for more than minimal harm
2022-06-29
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 2022-07-19
D · Potential for more than minimal harm
2022-06-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-20
D · Potential for more than minimal harm
2022-06-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-08
D · Potential for more than minimal harm
2022-06-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-07-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-23
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 2026-01-20
D · Potential for more than minimal harm
2025-12-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-20
E · Potential for more than minimal harm
2024-10-03
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-03
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 2024-11-03
D · Potential for more than minimal harm
2024-10-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-03
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-11-03
G · Actual harm
2023-05-10
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 2023-06-05
G · Actual harm
2023-05-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-05
Penalties and ownership
What sits behind the stars
Ownership
Meise, Susan
5% Or Greater Direct Ownership Interest · Individual
Shaffer, Sandra
5% Or Greater Direct Ownership Interest · Individual
Gorman, Brian
W-2 Managing Employee · Individual
Gorman, Thomas
Corporate Officer · Individual
Mazwell, Kathleen
Corporate Director · Individual
Mook, Vicki
W-2 Managing Employee · Individual
Peckham, Allen
Corporate Director · Individual
Scoles, Mark
Corporate Director · Individual
Sprecher, Gerald
Corporate Director · Individual
The People Community Bank
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Upland Hills Nursing And Rehab
Dodgeville, WI
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Maplewood Of Sauk Prairie
Sauk City, WI
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Rivers Edge Nursing and Rehab
Muscoda, WI
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $162,596 in total fines with 49 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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