Cycle 1
Health 2025-05-14 · Fire 2025-05-14
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Menasha, WI
Oakridge Gardens Nur Ctr, Inc
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1700 Midway Rd, Menasha, WI
(920) 739-0111
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
106
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-01-01
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
0.93
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.06
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.20
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.13
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.57
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
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
5.48
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,630
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9922
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.86
Baseline 20.85% · Performance 19.18% · Measure score 4.86 · Achievement 4.86 · Improvement 3.87
Healthcare-associated infections
2.92
Baseline 7.41% · Performance 6.96% · Measure score 2.92 · Achievement 2.92 · Improvement 1.36
Total nurse turnover
0.75
Baseline 50.00% · Performance 60.61% · Measure score 0.75 · Achievement 0.75 · Improvement 0
Adjusted total nurse staffing
7.14
Baseline 5.73 hours · Performance 5.11 hours · Measure score 7.14 · Achievement 7.14 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.79% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 145 · Observed rate 7.59% · Lower 95% interval 6.14% |
| Discharge to community | 56.85% |
50.57%
6.3 pts better
|
No Different than the National Rate · Eligible stays 144 · Observed rate 53.47% · Lower 95% interval 49.78% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 40 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 31.43% |
53.69%
22.3 pts worse
|
Numerator 11 · Denominator 35 |
| Discharge mobility score | 8.57% |
50.94%
42.4 pts worse
|
Numerator 3 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 40 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.96% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 5.97% · Lower 95% interval 4.11% |
| Staff COVID-19 vaccination coverage | 10.96% |
8.2%
2.8 pts better
|
Numerator 8 · Denominator 73 |
| Staff flu vaccination coverage | 83.67% |
42%
41.7 pts better
|
Numerator 123 · Denominator 147 |
| Discharge function score | 22.86% |
56.45%
33.6 pts worse
|
Numerator 8 · Denominator 35 |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · 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 | 98.4% |
95.7%
2.7 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.6% · Q4 95.8% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
95.0%
1.2 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.2%
1.1 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.1% · Q3 2.4% · Q4 2.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.2% |
5.0%
5.2 pts worse
|
11.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 8.3% · Q3 10.3% · Q4 13.3% · 4Q avg 10.2% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
4.9%
3.1 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
16.6%
0.4 pts worse
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 17.8% · Q3 15.0% · Q4 11.1% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.3% |
16.7%
0.4 pts better
|
16.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 15.8% · Q3 11.8% · Q4 20.5% · 4Q avg 16.3% · 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 | 16.0% |
21.1%
5.1 pts better
|
16.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 7.4% · Q3 16.9% · Q4 26.2% · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.2% |
17.3%
9.1 pts better
|
14.9%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 2.2% · Q3 7.5% · Q4 8.9% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
2.3%
0.2 pts better
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
3.0%
1.4 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.0% |
25.5%
1.5 pts better
|
19.8%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 21.2% · Q3 33.6% · Q4 27.3% · 4Q avg 24.0% |
| 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 4.7% · Q2 0.0% · Q3 2.8% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
86.8%
11.9 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 98.8% · Q3 98.9% · Q4 99.4% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.9% |
15.0%
5.1 pts better
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 9.1% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
82.2%
13.6 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.0% |
22.7%
3.3 pts worse
|
23.9%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.0% · Observed 21.8% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-03 · Fire 2024-04-03
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-02-08 · Fire 2023-02-08
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-14
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 2025-07-11
E · Potential for more than minimal harm
2025-05-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-11
E · Potential for more than minimal harm
2025-05-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-14
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-05-15
F · Potential for more than minimal harm
2024-04-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-16
F · Potential for more than minimal harm
2024-04-03
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-04-23
F · Potential for more than minimal harm
2024-04-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-11
E · Potential for more than minimal harm
2024-04-03
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-04-06
E · Potential for more than minimal harm
2024-04-03
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 2024-04-16
E · Potential for more than minimal harm
2024-04-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-04-03
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-04-06
F · Potential for more than minimal harm
2023-02-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-13
D · Potential for more than minimal harm
2023-02-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-14
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 2025-05-16
E · Potential for more than minimal harm
2025-05-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-05-14
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 2025-06-10
E · Potential for more than minimal harm
2025-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-14
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 2025-05-15
D · Potential for more than minimal harm
2025-05-14
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-05-14
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 2025-06-03
D · Potential for more than minimal harm
2025-05-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-02-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-10
F · Potential for more than minimal harm
2024-04-03
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 2024-04-25
D · Potential for more than minimal harm
2024-04-03
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 2024-04-25
D · Potential for more than minimal harm
2024-04-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-04-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-04-03
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-04-23
C · Minimal harm
2024-04-03
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-05-03
D · Potential for more than minimal harm
2023-08-29
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-04-18
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-18
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-02-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-08
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
2023-02-08
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 2023-03-03
B · Minimal harm
2023-02-08
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 2023-03-03
Penalties and ownership
What sits behind the stars
Ownership
Schanke, Michael
5% Or Greater Direct Ownership Interest · Individual
Schanke, Amy
Corporate Director · Individual
Schanke, Amy
Corporate Officer · Individual
Schanke, Michael
Corporate Director · Individual
Schanke, Michael
Corporate Officer · Individual
Schanke, Michael
W-2 Managing Employee · Individual
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#2
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1-star overall rating with 1-star inspections with $15,642 in total fines with 24 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Brewster Village
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5-star overall rating with 4-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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