Cycle 1
Health 2025-04-14 · Fire 2025-04-14
28 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
West Salem, WI
Mulder Health Care Facility
1-star overall rating with 1-star inspections with $292,588 in total fines with 28 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
713 Leonard St N, West Salem, WI
(608) 786-1600
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
87
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atrium Centers
Operator or chain grouping
Approved since
1968-11-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
26 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
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
0.85
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.96
CMS adjusted RN staffing hours
Adjusted total hours
3.96
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,834
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.94
Baseline 19.35% · Performance 21.00% · Measure score 0.94 · Achievement 0.94 · Improvement 0
Healthcare-associated infections
0
Baseline 7.77% · Performance 8.69% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.89
Baseline 54.84% · Performance 43.68% · Measure score 4.89 · Achievement 4.89 · Improvement 3.22
Adjusted total nurse staffing
3.11
Baseline 3.31 hours · Performance 3.96 hours · Measure score 3.11 · Achievement 3.11 · Improvement 2.14
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.37% |
10.72%
2.4 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 3.96% · Lower 95% interval 5.66% |
| Discharge to community | 44.36% |
50.57%
6.2 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 34.67% · Lower 95% interval 34.2% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 96.61% |
95.27%
1.3 pts better
|
Numerator 57 · Denominator 59 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 59 |
| Discharge self-care score | 20% |
53.69%
33.7 pts worse
|
Numerator 9 · Denominator 45 |
| Discharge mobility score | 28.89% |
50.94%
22 pts worse
|
Numerator 13 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 3.39% |
2.29%
1.1 pts worse
|
Numerator 2 · Denominator 59 · Adjusted rate 3.24% |
| Healthcare-associated infections requiring hospitalization | 8.69% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 14.04% · Lower 95% interval 5.07% |
| Staff COVID-19 vaccination coverage | 39.66% |
8.2%
31.5 pts better
|
Numerator 46 · Denominator 116 |
| Staff flu vaccination coverage | 18.7% |
42%
23.3 pts worse
|
Numerator 23 · Denominator 123 |
| Discharge function score | 31.11% |
56.45%
25.3 pts worse
|
Numerator 14 · Denominator 45 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 47.06% |
25.2%
21.9 pts better
|
Numerator 16 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.3 · Expected 2.4 · 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 1.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
95.7%
1.3 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 98.6% · Q3 98.5% · Q4 93.8% · 4Q avg 97.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
95.0%
3.8 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.2%
2.8 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · 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 3.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
4.9%
1.9 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.3% · Q3 0.0% · Q4 5.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
16.6%
6.2 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 14.5% · Q3 13.6% · Q4 6.6% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.0% |
16.7%
3.3 pts worse
|
16.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 20.4% · Q3 20.4% · Q4 22.4% · 4Q avg 20.0% · 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 | 11.5% |
21.1%
9.6 pts better
|
16.3%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 7.2% · Q3 15.3% · Q4 18.5% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.3% |
17.3%
10 pts better
|
14.9%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.6% · Q3 6.9% · Q4 10.3% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
2.3%
1.6 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
3.0%
2.6 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.8% |
25.5%
17.7 pts better
|
19.8%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 5.9% · Q3 4.6% · Q4 7.7% · 4Q avg 7.8% |
| 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 0.0% · Q2 0.0% · Q3 1.7% · Q4 5.7% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.9% |
86.8%
2.9 pts worse
|
81.7%
2.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 77.1% · Q2 77.4% · Q3 89.3% · Q4 88.3% · 4Q avg 83.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
15.0%
5.2 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 10.5% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.3%
1.3 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 5.9% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.0% |
82.2%
2.2 pts worse
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.0% |
22.7%
5.7 pts better
|
23.9%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 17.5% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-22 · Fire 2024-02-22
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-12-30 · Fire 2022-12-30
19 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-04-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-04-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-14
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 2025-06-16
E · Potential for more than minimal harm
2025-04-14
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 2025-05-09
E · Potential for more than minimal harm
2025-04-14
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-14
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-09
F · Potential for more than minimal harm
2022-12-30
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-12-30
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 2023-01-20
D · Potential for more than minimal harm
2022-12-30
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-01-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-22
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2026-02-16
E · Potential for more than minimal harm
2026-01-22
F803 · Nutrition and Dietary Deficiencies
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 2026-02-16
E · Potential for more than minimal harm
2026-01-22
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 2026-02-16
D · Potential for more than minimal harm
2026-01-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-02-16
E · Potential for more than minimal harm
2025-09-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-16
D · Potential for more than minimal harm
2025-09-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-16
D · Potential for more than minimal harm
2025-09-16
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 2025-10-16
D · Potential for more than minimal harm
2025-09-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-16
L · Immediate jeopardy
2025-04-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-09
J · Immediate jeopardy
2025-04-14
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2025-05-09
G · Actual harm
2025-04-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-04-14
F838 · Administration Deficiencies
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 2025-05-09
F · Potential for more than minimal harm
2025-04-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-14
F700 · Quality of Life and Care Deficiencies
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 2025-05-09
E · Potential for more than minimal harm
2025-04-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-14
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 2025-05-09
D · Potential for more than minimal harm
2025-04-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-14
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-14
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-14
F625 · Resident Rights Deficiencies
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 2025-05-09
D · Potential for more than minimal harm
2025-04-14
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-14
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-14
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-05-09
D · Potential for more than minimal harm
2024-12-16
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 2024-12-31
J · Immediate jeopardy
2024-11-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-07-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-14
F · Potential for more than minimal harm
2024-02-22
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-03-21
F · Potential for more than minimal harm
2024-02-22
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 2024-03-21
E · Potential for more than minimal harm
2024-02-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-21
E · Potential for more than minimal harm
2024-02-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-22
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-22
F657 · Resident Assessment and Care Planning Deficiencies
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 2024-03-21
D · Potential for more than minimal harm
2024-02-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-22
F690 · Quality of Life and Care Deficiencies
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 2024-03-21
F · Potential for more than minimal harm
2023-12-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-12-15
F887 · Infection Control Deficiencies
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 2024-01-17
D · Potential for more than minimal harm
2023-10-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-18
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 2023-11-09
E · Potential for more than minimal harm
2023-04-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-10
F585 · Resident Rights Deficiencies
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 2023-05-12
D · Potential for more than minimal harm
2023-04-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-14
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 2023-04-12
D · Potential for more than minimal harm
2023-03-14
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-03-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-11
D · Potential for more than minimal harm
2023-03-14
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-04-11
G · Actual harm
2022-12-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-27
F · Potential for more than minimal harm
2022-12-30
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 2023-01-27
D · Potential for more than minimal harm
2022-12-30
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-12-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-12-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-12-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-12-30
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-12-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-27
Penalties and ownership
What sits behind the stars
$278,155
2025-04-14
Fine
Fine · fine $278,155
Fine
$14,433
2024-11-04
Fine
Fine · fine $14,433
Fine
Ownership
Orion Operating Services LLC
5% Or Greater Direct Ownership Interest · Organization
Albright Ross, Susan
Operational/Managerial Control · Individual
Albright Ross, Susan
Corporate Officer · Individual
Albright Ross, Susan
W-2 Managing Employee · Individual
Atrium Centers, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Bailey, Essel
5% Or Greater Indirect Ownership Interest · Individual
Bailey, Essel
Corporate Officer · Individual
Finney, Donald
5% Or Greater Indirect Ownership Interest · Individual
Finney, Donald
Corporate Officer · Individual
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5-star overall rating with 5-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Onalaska Care Center
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4-star overall rating with 3-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Hillview Health Care Ctr
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4-star overall rating with 3-star inspections with $15,593 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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