10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Marinette, WI
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
831 Pine Beach Rd, Marinette, WI
(715) 732-0155
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
80
Certified beds
Average residents
62
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-08-01
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
0.68
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.77
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.15
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.83
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
4.82
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
8,545
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.17
Baseline 17.03% · Performance 20.43% · Measure score 2.17 · Achievement 2.17 · Improvement 0
Healthcare-associated infections
0.65
Baseline 7.40% · Performance 7.64% · Measure score 0.65 · Achievement 0.65 · Improvement 0
Total nurse turnover
3.93
Baseline 56.25% · Performance 47.62% · Measure score 3.93 · Achievement 3.93 · Improvement 2.25
Adjusted total nurse staffing
3.80
Baseline 2.43 hours · Performance 3.87 hours · Measure score 3.80 · Achievement 2.78 · Improvement 3.80
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.03% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 90 · Observed rate 18.89% · Lower 95% interval 9.38% |
| Discharge to community | 44.15% |
50.57%
6.4 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 36.25% · Lower 95% interval 34.02% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 94.87% |
95.27%
0.4 pts worse
|
Numerator 37 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 61.29% |
53.69%
7.6 pts better
|
Numerator 19 · Denominator 31 |
| Discharge mobility score | 58.06% |
50.94%
7.1 pts better
|
Numerator 18 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 39 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.64% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 10% · Lower 95% interval 3.98% |
| Staff COVID-19 vaccination coverage | 7.63% |
8.2%
0.6 pts worse
|
Numerator 9 · Denominator 118 |
| Staff flu vaccination coverage | 63.13% |
42%
21.1 pts better
|
Numerator 101 · Denominator 160 |
| Discharge function score | 74.19% |
56.45%
17.7 pts better
|
Numerator 23 · Denominator 31 |
| 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 | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| 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 |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.2
1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.5 · 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 | 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 | 3.3% |
3.2%
0.1 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.8% · Q3 3.9% · Q4 3.8% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
5.0%
1.9 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 10.4% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
4.9%
3 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 2.2% · Q3 9.5% · Q4 14.0% · 4Q avg 7.9% |
| 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 21.3% · Q2 17.4% · Q3 25.0% · Q4 22.7% · 4Q avg 21.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.0% |
16.7%
11.3 pts worse
|
16.7%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 27.3% · Q3 32.4% · Q4 34.5% · 4Q avg 28.0% · 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 | 13.4% |
21.1%
7.7 pts better
|
16.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 9.0% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.3% |
17.3%
5 pts better
|
14.9%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 8.7% · Q3 13.6% · Q4 11.4% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.8% |
2.3%
1.5 pts worse
|
1.0%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.5% · Q3 2.3% · Q4 4.0% · 4Q avg 3.8% · 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 · Q1 1.9% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.5% |
25.5%
8 pts better
|
19.8%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 22.2% · Q3 22.9% · Q4 7.0% · 4Q avg 17.5% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.5%
0.5 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 8.7% · Q3 4.0% · Q4 4.9% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
86.8%
8.7 pts better
|
81.7%
13.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 95.9% · Q3 96.6% · Q4 97.1% · 4Q avg 95.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.2% |
15.0%
0.2 pts worse
|
12.0%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.2% · Observed 14.0% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.3%
1.2 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.4% · Q3 0.0% · Q4 3.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
82.2%
9.8 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
22.7%
0.2 pts better
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 18.6% · Expected 19.7% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Rights (3 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2026-01-10
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-10
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-09-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-03-31
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-01-10
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-10
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-09-23
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-09-23
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-09-23
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-23
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-23
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-23
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 2024-09-23
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 2024-09-23
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-23
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-23
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-23
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-23
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-23
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-09-23
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-09-23
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-23
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 2024-09-23
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-23
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-07-07
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-07-07
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-07
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 2023-07-07
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-07-07
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-07
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-07
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-07-07
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-07-07
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-07-07
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-07
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-07
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-07
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-07
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-07
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-10
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2026-01-10
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2026-01-10
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-01-10
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-01-10
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-10
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2026-01-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-10
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-10
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-10
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-30
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-11-30
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-23
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-23
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-09-23
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-09-23
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-17
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-16
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 2023-10-16
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-07
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-07
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-07-07
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-07
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
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
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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