15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Watertown, WI
1-star overall rating with 2-star inspections with $40,480 in total fines with 15 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1020 Hill St, Watertown, WI
(920) 261-0400
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
140
Certified beds
Average residents
80
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-08-01
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
0.21
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
2.92
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
0.89
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.64
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
2.79
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
4,668
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9920
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
8.56
Baseline 18.75% · Performance 17.46% · Measure score 8.56 · Achievement 8.56 · Improvement 6.99
Healthcare-associated infections
5.10
Baseline 6.50% · Performance 6.31% · Measure score 5.10 · Achievement 5.10 · Improvement 0.75
Total nurse turnover
0.33
Baseline 69.49% · Performance 65.79% · Measure score 0.33 · Achievement 0 · Improvement 0.33
Adjusted total nurse staffing
1.62
Baseline 2.01 hours · Performance 2.81 hours · Measure score 1.62 · Achievement 0 · Improvement 1.62
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.82% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 206 · Observed rate 5.83% · Lower 95% interval 5.95% |
| Discharge to community | 45.48% |
50.57%
5.1 pts worse
|
No Different than the National Rate · Eligible stays 173 · Observed rate 43.93% · Lower 95% interval 39.86% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 99 · Denominator 99 |
| Falls with major injury | 1.01% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 99 |
| Discharge self-care score | 30.67% |
53.69%
23 pts worse
|
Numerator 23 · Denominator 75 |
| Discharge mobility score | 48% |
50.94%
2.9 pts worse
|
Numerator 36 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 3 · Denominator 99 · Adjusted rate 2.7% |
| Healthcare-associated infections requiring hospitalization | 6.31% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 4.26% · Lower 95% interval 3.48% |
| Staff COVID-19 vaccination coverage | 12.17% |
8.2%
4 pts better
|
Numerator 14 · Denominator 115 |
| Staff flu vaccination coverage | 60.19% |
42%
18.2 pts better
|
Numerator 65 · Denominator 108 |
| Discharge function score | 38.67% |
56.45%
17.8 pts worse
|
Numerator 29 · Denominator 75 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 63 · Denominator 63 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 51.92% |
25.2%
26.7 pts better
|
Numerator 27 · Denominator 52 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 2.0 · 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 | 98.8% |
95.7%
3.1 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.9% |
95.0%
0.9 pts better
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.2%
1 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.5% · Q3 4.7% · Q4 6.1% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
5.0%
4.6 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
4.9%
About the same
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.5% · Q3 5.4% · Q4 6.9% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.8% |
16.6%
11.2 pts worse
|
19.6%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 29.8% · Q3 28.6% · Q4 27.6% · 4Q avg 27.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.7% |
16.7%
8 pts worse
|
16.7%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 23.1% · Q3 26.5% · Q4 25.5% · 4Q avg 24.7% · 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 | 38.1% |
21.1%
17 pts worse
|
16.3%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.1% |
17.3%
4.8 pts worse
|
14.9%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 24.0% · Q3 23.1% · Q4 11.5% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.1% |
2.3%
3.8 pts worse
|
1.0%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 4.6% · Q3 6.6% · Q4 5.6% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
3.0%
0.8 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.5% · Q3 4.7% · Q4 4.5% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.3% |
25.5%
3.8 pts worse
|
19.8%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 39.9% · Q3 23.3% · Q4 28.9% · 4Q avg 29.3% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.5%
1.8 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.8% · Q3 2.3% · Q4 4.4% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.0% |
86.8%
1.2 pts better
|
81.7%
6.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.5% · Q2 93.8% · Q3 87.4% · Q4 80.6% · 4Q avg 88.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
15.0%
1.4 pts better
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 14.3% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.3%
0.5 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.0% |
82.2%
2.8 pts better
|
79.7%
5.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
22.7%
1.6 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 23.1% · Expected 22.6% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-10-28
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-28
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-10-28
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-28
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-10-28
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-10-28
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-28
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-28
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-07-28
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2023-07-28
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-07-28
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-28
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 2023-07-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-28
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-28
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-28
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-28
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 2023-07-28
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-07-28
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-07-28
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-28
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-06
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 2022-07-07
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-07-07
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 2023-07-06
Inspection history
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-12-17
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-17
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-24
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-24
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-04-01
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-04-01
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-28
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-10-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-28
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-28
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-28
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-10-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-20
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-15
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-28
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-28
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-07-28
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 2023-07-28
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-07-28
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-28
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-28
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 2023-07-28
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-07-28
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 2022-07-07
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-07-07
Health
Provide appropriate foot care.
Corrected 2022-07-07
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-07-07
Penalties and ownership
Fine · fine $40,480
Fine
Payment Denial · denial start 2025-05-09 · 15 days
15 day denial
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Nearby options
Watertown, WI
1-star overall rating with 1-star inspections with $276,120 in total fines with 20 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
Oconomowoc, WI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Lake Mills, WI
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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