Cycle 1
Health 2025-06-04 · Fire 2025-06-04
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Dousman, WI
Masonic Center For Health & Rehab Inc
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
410 N Main St, Dousman, WI
(262) 965-7245
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
45
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-07-01
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
1.05
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.24
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.12
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.89
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.63
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.57
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
1.18
CMS adjusted RN staffing hours
Adjusted total hours
5.75
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
20%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,186
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.07
Composite VBP score used to determine payment impact.
Payment multiplier
1.0143
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.07
Baseline 17.54% · Performance 18.62% · Measure score 6.07 · Achievement 6.07 · Improvement 0
Healthcare-associated infections
1.73
Baseline 6.04% · Performance 7.32% · Measure score 1.73 · Achievement 1.73 · Improvement 0
Total nurse turnover
7.22
Baseline 43.66% · Performance 34.18% · Measure score 7.22 · Achievement 7.22 · Improvement 4.54
Adjusted total nurse staffing
8.61
Baseline 5.31 hours · Performance 5.53 hours · Measure score 8.61 · Achievement 8.61 · Improvement 4.09
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.34% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 149 · Observed rate 7.38% · Lower 95% interval 6.76% |
| Discharge to community | 70.48% |
50.57%
19.9 pts better
|
Better than the National Rate · Eligible stays 141 · Observed rate 75.89% · Lower 95% interval 64.22% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 105 · Denominator 105 |
| Falls with major injury | 0.95% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 105 |
| Discharge self-care score | 60% |
53.69%
6.3 pts better
|
Numerator 51 · Denominator 85 |
| Discharge mobility score | 48.24% |
50.94%
2.7 pts worse
|
Numerator 41 · Denominator 85 |
| Pressure ulcers or injuries, new or worsened | 1.9% |
2.29%
0.4 pts better
|
Numerator 2 · Denominator 105 · Adjusted rate 2.74% |
| Healthcare-associated infections requiring hospitalization | 7.32% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 89 · Observed rate 5.62% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 6.9% |
8.2%
1.3 pts worse
|
Numerator 10 · Denominator 145 |
| Staff flu vaccination coverage | 83.44% |
42%
41.4 pts better
|
Numerator 131 · Denominator 157 |
| Discharge function score | 61.18% |
56.45%
4.7 pts better
|
Numerator 52 · Denominator 85 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 76 · Denominator 76 |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 29 · Denominator 58 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.6
0.5 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
2.2
1.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.3 · 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 | 4.7% |
3.2%
1.5 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.3% · Q3 6.1% · Q4 3.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
5.0%
4.2 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.9%
4.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.9% |
16.6%
2.3 pts worse
|
19.6%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 23.8% · Q3 17.4% · Q4 11.5% · 4Q avg 18.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.9% |
16.7%
5.2 pts worse
|
16.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.9% · 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 | 25.6% |
21.1%
4.5 pts worse
|
16.3%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.8% |
17.3%
14.5 pts worse
|
14.9%
16.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 30.0% · Q3 22.7% · Q4 33.3% · 4Q avg 31.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
3.0%
0.6 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.5% · Q4 3.1% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.4% |
25.5%
1.1 pts better
|
19.8%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 30.4% · Q3 26.0% · Q4 23.9% · 4Q avg 24.4% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.5%
2.4 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 4.7% · Q4 2.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
86.8%
6.6 pts better
|
81.7%
11.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 98.2% · Q3 91.8% · Q4 90.5% · 4Q avg 93.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
15.0%
8 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 6.2% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.5% |
82.2%
1.3 pts better
|
79.7%
3.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
22.7%
2.6 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 16.2% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-11 · Fire 2024-04-11
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-02-09 · Fire 2023-02-09
0 health deficiencies
No concentrated health issue counts in this cycle.
14 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-04
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-06-04
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-06-04
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-07-03
F · Potential for more than minimal harm
2024-04-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-07
E · Potential for more than minimal harm
2024-04-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-04-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-22
F · Potential for more than minimal harm
2023-02-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-02-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-23
F · Potential for more than minimal harm
2023-02-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-02-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-24
E · Potential for more than minimal harm
2023-02-09
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-02-28
E · Potential for more than minimal harm
2023-02-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-02-24
E · Potential for more than minimal harm
2023-02-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-09
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-02-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-24
E · Potential for more than minimal harm
2023-02-09
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-02-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-02-09
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 2023-04-28
D · Potential for more than minimal harm
2023-02-09
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-04-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-25
F · Potential for more than minimal harm
2025-06-04
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 2025-07-03
D · Potential for more than minimal harm
2025-06-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-03
Penalties and ownership
What sits behind the stars
Ownership
Wisconsin Masonic Home, Inc
5% Or Greater Direct Ownership Interest · Organization
Chapman, Carly
Operational/Managerial Control · Individual
Chapman, Carly
W-2 Managing Employee · Individual
Freuck, Jean
Operational/Managerial Control · Individual
Freuck, Jean
Corporate Director · Individual
Freuck, Jean
Corporate Officer · Individual
Freuck, Jean
W-2 Managing Employee · Individual
Gervais, Lisa
Contracted Managing Employee · Individual
Mcleer, James
Corporate Director · Individual
Strautman, Mark
Operational/Managerial Control · Individual
Strautman, Mark
Corporate Director · Individual
Strautman, Mark
Corporate Officer · Individual
Strautman, Mark
W-2 Managing Employee · Individual
Vandenberg, Josh
Operational/Managerial Control · Individual
Vandenberg, Josh
W-2 Managing Employee · Individual
Wisconsin Masonic Home, Inc
5% Or Greater Security Interest · Organization
Wisconsin Masonic Home, Inc
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Lake Country Health Services
Oconomowoc, WI
2-star overall rating with 2-star inspections with $185,950 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Shorehaven Hlth & Rehab Ctr
Oconomowoc, WI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Lindengrove Waukesha
Waukesha, WI
1-star overall rating with 1-star inspections with $39,621 in total fines with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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