Berlin, WI
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
482 Oak Street, Berlin, WI
(920) 361-3092
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
37
Certified beds
Average residents
35
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1977-12-01
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
RN hours / resident day
1.76
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.39
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.84
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.99
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.14
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.26
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.48
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.72
CMS adjusted RN staffing hours
Adjusted total hours
4.88
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
3,340
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9980
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.70
Baseline 19.99% · Performance 19.25% · Measure score 4.70 · Achievement 4.70 · Improvement 1.98
Healthcare-associated infections
4.44
Baseline 5.60% · Performance 6.51% · Measure score 4.44 · Achievement 4.44 · Improvement 0
Total nurse turnover
1.84
Baseline 70.21% · Performance 59.61% · Measure score 1.84 · Achievement 0.99 · Improvement 1.84
Adjusted total nurse staffing
6.95
Baseline 4.37 hours · Performance 5.06 hours · Measure score 6.95 · Achievement 6.95 · Improvement 4.37
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.95% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 7.02% · Lower 95% interval 6.25% |
| Discharge to community | 47.55% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 43.4% · Lower 95% interval 37.03% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.3% |
95.27%
1 pts better
|
Numerator 26 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | 42.31% |
53.69%
11.4 pts worse
|
Numerator 11 · Denominator 26 |
| Discharge mobility score | 57.69% |
50.94%
6.8 pts better
|
Numerator 15 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 27 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.51% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 3.7% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | 5.13% |
8.2%
3.1 pts worse
|
Numerator 4 · Denominator 78 |
| Staff flu vaccination coverage | 90.43% |
42%
48.4 pts better
|
Numerator 104 · Denominator 115 |
| Discharge function score | 30.77% |
56.45%
25.7 pts worse
|
Numerator 8 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 5% |
96.28%
91.3 pts worse
|
Numerator 1 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
95.7%
3.1 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.8% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
95.0%
1.2 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.2%
2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 4.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
5.0%
3.6 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 9.0% |
4.9%
4.1 pts worse
|
5.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q4 5.0% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.8% |
16.6%
6.2 pts worse
|
19.6%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q4 20.0% · 4Q avg 22.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.5% |
16.7%
1.8 pts worse
|
16.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.5% · 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% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.9% |
17.3%
1.4 pts better
|
14.9%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.9% |
2.3%
3.6 pts worse
|
1.0%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
3.0%
0.7 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
25.5%
0.8 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 17.0% |
5.5%
11.5 pts worse
|
5.1%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q4 21.2% · 4Q avg 17.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
86.8%
11.9 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.6% · Q3 99.1% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
15.0%
1.1 pts better
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 14.3% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.9% |
82.2%
16.7 pts better
|
79.7%
19.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
22.7%
1.4 pts worse
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 21.4% · Expected 21.2% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-27
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-27
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-02-27
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-23
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-02-23
Inspection history
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-10
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-10
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-03-05
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-05
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-05
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-26
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-02
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-02
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-15
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2022-12-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-12-15
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-15
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-12-15
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-12-15
Penalties and ownership
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Nearby options
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