Westby, WI

Norseland Nursing Home

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

Compare this facility

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

Facility snapshot

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

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

0.97

Registered nurse staffing · state 0.97 · national 0.68

LPN hours / resident day

0.46

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.35

Nurse aide staffing · state 2.59 · national 2.35

Total nurse hours

3.78

All reported nurse hours · state 4.20 · national 3.89

Licensed hours

1.43

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.38

Weekend nurse staffing · state 3.72 · national 3.43

Weekend RN hours

0.61

Weekend registered nurse coverage · state 0.66 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.98

CMS adjusted RN staffing hours

Adjusted total hours

3.80

CMS adjusted total nurse staffing hours

Case-mix index

1.36

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

34%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,794

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

47.71

Composite VBP score used to determine payment impact.

Payment multiplier

1.0013

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

6.21

Baseline 34.69% · Performance 38.30% · Measure score 6.21 · Achievement 6.21 · Improvement 0

Adjusted total nurse staffing

3.33

Baseline 4.27 hours · Performance 4.03 hours · Measure score 3.33 · Achievement 3.33 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.53%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 28 · Observed rate 7.14% · Lower 95% interval 6.42%
Discharge to community	43.87%	50.57% 6.7 pts worse	No Different than the National Rate · Eligible stays 26 · Observed rate 38.46% · Lower 95% interval 28.87%
Medicare spending per beneficiary	1.07	1.02 0.1 pts worse
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0.83%	8.2% 7.4 pts worse	Numerator 1 · Denominator 121
Staff flu vaccination coverage	16.33%	42% 25.7 pts worse	Numerator 16 · Denominator 98
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

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 · 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	97.1%	95.0% 2.1 pts better	95.5% 1.6 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1%
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 · Q1 3.0% · Q2 3.0% · Q3 0.0% · Q4 3.2% · 4Q avg 2.4% · Used in QM five-star
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 · Q1 6.1% · Q2 3.4% · Q3 3.3% · Q4 0.0% · 4Q avg 3.3%
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 · Q1 7.4% · Q2 6.9% · Q3 15.4% · Q4 3.8% · 4Q avg 8.3%
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 · Q1 21.4% · Q2 20.0% · Q3 23.1% · Q4 23.1% · 4Q avg 21.8%
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 · Q1 15.4% · Q2 22.2% · Q3 8.7% · Q4 9.1% · 4Q avg 14.3% · 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	38.0%	21.1% 16.9 pts worse	16.3% 21.7 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 38.0% · Used in QM five-star
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 · Q1 23.1% · Q2 25.0% · Q3 17.4% · Q4 0.0% · 4Q avg 17.0% · Used in QM five-star
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 · Q1 8.8% · Q2 2.3% · Q3 0.0% · Q4 2.1% · 4Q avg 3.4% · 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 3.1% · Q2 6.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star
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 · Q1 31.0% · Q2 12.6% · Q3 25.6% · Q4 24.6% · 4Q avg 23.3%
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 · Q1 9.0% · Q2 11.9% · Q3 0.0% · Q4 0.0% · 4Q avg 5.3% · Used in QM five-star
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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
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 · Q1 4.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star
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 · 4Q avg 94.3%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-19 · Fire 2025-06-19

3 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

7 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Cycle 2 Health 2024-05-01 · Fire 2024-05-01

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2023-02-09 · Fire 2023-02-09

4 health deficiencies

Top issue: Infection Control (2 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-06-19

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-07-24

F · Potential for more than minimal harm 2025-06-19

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2025-06-26

E · Potential for more than minimal harm 2025-06-19

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 2025-08-14

E · Potential for more than minimal harm 2025-06-19

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2025-07-24

D · Potential for more than minimal harm 2025-06-19

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-08-12

D · Potential for more than minimal harm 2025-06-19

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-07-24

C · Minimal harm 2025-06-19

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2025-10-22

E · Potential for more than minimal harm 2024-05-01

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 2024-05-01

E · Potential for more than minimal harm 2023-02-09

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 2023-02-09

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 2023-02-09

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 2023-03-01

D · Potential for more than minimal harm 2023-02-09

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-02-27

D · Potential for more than minimal harm 2023-02-09

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-02-09

D · Potential for more than minimal harm 2023-02-09

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-02-09

D · Potential for more than minimal harm 2023-02-09

K741 · Miscellaneous Deficiencies

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

Recent health citations

F · Potential for more than minimal harm 2025-06-19

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 2025-07-24

E · Potential for more than minimal harm 2025-06-19

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-07-24

D · Potential for more than minimal harm 2025-06-19

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-07-24

G · Actual harm 2024-05-01

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 2024-05-29

F · Potential for more than minimal harm 2024-05-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-29

E · Potential for more than minimal harm 2024-05-01

F688 · Quality of Life and Care Deficiencies

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

E · Potential for more than minimal harm 2024-05-01

F711 · Nursing and Physician Services Deficiencies

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

D · Potential for more than minimal harm 2024-05-01

F578 · Resident Rights Deficiencies

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

D · Potential for more than minimal harm 2024-05-01

F655 · Resident Assessment and Care Planning Deficiencies

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

D · Potential for more than minimal harm 2024-05-01

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-05-01

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-05-01

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 2024-05-29

D · Potential for more than minimal harm 2024-05-01

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 2024-05-29

C · Minimal harm 2024-05-01

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-05-29

E · Potential for more than minimal harm 2023-02-09

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2023-03-03

D · Potential for more than minimal harm 2023-02-09

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 2023-02-23

D · Potential for more than minimal harm 2023-02-09

F688 · Quality of Life and Care Deficiencies

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

D · Potential for more than minimal harm 2023-02-09

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 2023-02-22

Penalties and ownership