14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Washburn, WI
3-star overall rating with 2-star inspections with $15,945 in total fines with 14 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
706 Bratley Dr, Washburn, WI
(715) 373-5621
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
50
Certified beds
Average residents
47
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-04-25
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
0.84
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.05
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
4.54
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
5,150
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9905
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.48
Baseline 16.95% · Performance 19.36% · Measure score 4.48 · Achievement 4.48 · Improvement 0
Healthcare-associated infections
2.97
Baseline 6.59% · Performance 6.95% · Measure score 2.97 · Achievement 2.97 · Improvement 0
Total nurse turnover
5.09
Baseline 54.35% · Performance 42.86% · Measure score 5.09 · Achievement 5.09 · Improvement 3.40
Adjusted total nurse staffing
2.35
Baseline 4.03 hours · Performance 3.75 hours · Measure score 2.35 · Achievement 2.35 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.52% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 13.41% · Lower 95% interval 7.48% |
| Discharge to community | 51.57% |
50.57%
1 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 44.3% · Lower 95% interval 41.12% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.41% |
95.27%
3.1 pts better
|
Numerator 62 · Denominator 63 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 63 |
| Discharge self-care score | 57.45% |
53.69%
3.8 pts better
|
Numerator 27 · Denominator 47 |
| Discharge mobility score | 51.06% |
50.94%
0.1 pts better
|
Numerator 24 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 1.59% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 63 · Adjusted rate 1.81% |
| Healthcare-associated infections requiring hospitalization | 6.95% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 6.25% · Lower 95% interval 3.91% |
| Staff COVID-19 vaccination coverage | 9.8% |
8.2%
1.6 pts better
|
Numerator 5 · Denominator 51 |
| Staff flu vaccination coverage | 43.64% |
42%
1.6 pts better
|
Numerator 48 · Denominator 110 |
| Discharge function score | 68.09% |
56.45%
11.6 pts better
|
Numerator 32 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 32 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 46.88% |
25.2%
21.7 pts better
|
Numerator 15 · Denominator 32 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.8 |
2.2
2.6 pts worse
|
1.8
3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.8 · Observed 4.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
95.7%
1.1 pts better
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 92.3% · Q3 100.0% · Q4 100.0% · 4Q avg 96.8% |
| 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 | 1.9% |
3.2%
1.3 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 0.0% · Q4 2.4% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
5.0%
1.6 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.6% · Q3 2.9% · Q4 2.6% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
4.9%
3.2 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 8.1% · Q3 10.0% · Q4 13.3% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.0% |
16.6%
8.4 pts worse
|
19.6%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 23.7% · Q3 32.3% · Q4 37.1% · 4Q avg 25.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.2% |
16.7%
0.5 pts better
|
16.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 17.9% · Q3 15.4% · Q4 17.9% · 4Q avg 16.2% · 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 | 15.6% |
21.1%
5.5 pts better
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
17.3%
8.2 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 14.7% · Q3 12.5% · Q4 6.9% · 4Q avg 9.1% · 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 | 1.4% |
3.0%
1.6 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
25.5%
0.3 pts worse
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 22.7% · Q3 12.9% · Q4 35.6% · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.5%
3.5 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 2.8% · Q4 2.3% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.7% |
86.8%
1.1 pts worse
|
81.7%
4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 79.2% · Q2 83.0% · Q3 91.1% · Q4 91.9% · 4Q avg 85.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.4% |
15.0%
8.4 pts worse
|
12.0%
11.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 22.2% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.6% |
1.3%
2.3 pts worse
|
1.6%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 0.0% · Q3 3.4% · Q4 4.5% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.6% |
82.2%
7.4 pts better
|
79.7%
9.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 7.8% |
22.7%
14.9 pts better
|
23.9%
16.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 6.7% · Expected 20.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-09-11
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-09-11
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 2025-09-11
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-09-11
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-09-11
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-11
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-09-11
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-09-11
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-09-11
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-09-11
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-06-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-21
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-06-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-21
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-06-21
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-21
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-19
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-19
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-19
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-06-19
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-06-19
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-06-19
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-10
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-10
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-10
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-25
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-25
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-25
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-25
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 2025-08-25
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-25
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 2025-08-25
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 2025-08-25
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-25
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-17
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-04-12
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 2024-06-17
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-06-17
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 2024-06-17
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-17
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-17
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 2024-06-17
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-17
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 2023-06-09
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-09
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-09
Health
Assess the resident when there is a significant change in condition
Corrected 2023-06-09
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-06-09
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-09
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-09
Penalties and ownership
Fine · fine $15,945
Fine
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
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Ironwood, MI
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