3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Westby, WI
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
323 Black River Ave, Westby, WI
(608) 634-3747
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
59
Certified beds
Average residents
41
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.97
Registered nurse staffing
LPN hours / resident day
0.46
Licensed practical nurse staffing
Aide hours / resident day
2.35
Nurse aide staffing
Weekend hours
3.38
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
34%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
95.0%
2.1 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.2%
0.8 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
5.0%
1.7 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.3% |
4.9%
3.4 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.8% |
16.6%
5.2 pts worse
|
19.6%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
16.7%
2.4 pts better
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 38.0% |
21.1%
16.9 pts worse
|
16.3%
21.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.0% |
17.3%
0.3 pts better
|
14.9%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
2.3%
1.1 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
25.5%
2.2 pts better
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.5%
0.2 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.8%
13.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
82.2%
12.1 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-07-24
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-06-26
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 2025-08-14
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-07-24
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-08-12
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-24
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-10-22
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 2024-05-01
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 2023-02-09
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-09
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-01
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-02-27
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-09
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-09
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-02-09
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-24
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-24
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-29
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-29
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-05-29
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-05-29
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 2024-05-29
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-05-29
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-29
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-29
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-05-29
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 2024-05-29
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-05-29
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-03
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-02-23
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-03-03
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 2023-02-22
Penalties and ownership
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
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Sparta, WI
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