Cycle 1
Health 2025-09-10 · Fire 2025-09-10
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Park Falls, WI
Park Manor Ltd
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
250 Lawrence Ave, Park Falls, WI
(715) 762-2449
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
92
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-03-01
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
1.19
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.25
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.62
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.99
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.25
CMS adjusted RN staffing hours
Adjusted total hours
4.14
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,764
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9958
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.13
Baseline 20.05% · Performance 19.98% · Measure score 3.13 · Achievement 3.13 · Improvement 0
Healthcare-associated infections
7.77
Baseline 6.82% · Performance 5.51% · Measure score 7.77 · Achievement 7.77 · Improvement 6.67
Total nurse turnover
4.21
Baseline 42.47% · Performance 46.48% · Measure score 4.21 · Achievement 4.21 · Improvement 0
Adjusted total nurse staffing
2
Baseline 3.19 hours · Performance 3.65 hours · Measure score 2 · Achievement 2 · Improvement 1.26
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.6% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 143 · Observed rate 7.69% · Lower 95% interval 6.96% |
| Discharge to community | 53.68% |
50.57%
3.1 pts better
|
No Different than the National Rate · Eligible stays 115 · Observed rate 51.3% · Lower 95% interval 46.2% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 97 · Denominator 97 |
| Falls with major injury | 3.09% |
0.77%
2.3 pts worse
|
Numerator 3 · Denominator 97 |
| Discharge self-care score | 63.24% |
53.69%
9.6 pts better
|
Numerator 43 · Denominator 68 |
| Discharge mobility score | 54.41% |
50.94%
3.5 pts better
|
Numerator 37 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 97 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.51% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 1.32% · Lower 95% interval 2.71% |
| Staff COVID-19 vaccination coverage | 7.14% |
8.2%
1.1 pts worse
|
Numerator 9 · Denominator 126 |
| Staff flu vaccination coverage | 46.09% |
42%
4.1 pts better
|
Numerator 59 · Denominator 128 |
| Discharge function score | 66.18% |
56.45%
9.7 pts better
|
Numerator 45 · Denominator 68 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | 97.44% |
96.28%
1.2 pts better
|
Numerator 38 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 36.73% |
25.2%
11.5 pts better
|
Numerator 18 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.5 |
2.2
3.3 pts worse
|
1.8
3.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.5 · Observed 5.3 · Expected 1.6 · Used in QM five-star |
| 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 | 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 | 3.5% |
3.2%
0.3 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.2% · Q3 3.1% · Q4 6.2% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 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 who lose too much weight | 6.3% |
4.9%
1.4 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.5% · Q3 3.3% · Q4 15.0% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.1% |
16.6%
1.5 pts worse
|
19.6%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 17.5% · Q3 15.6% · Q4 14.5% · 4Q avg 18.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
16.7%
7.6 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 10.2% · Q3 9.1% · Q4 10.0% · 4Q avg 9.1% · 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 | 26.2% |
21.1%
5.1 pts worse
|
16.3%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 19.0% · Q3 22.2% · Q4 31.2% · 4Q avg 26.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.5% |
17.3%
11.2 pts worse
|
14.9%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 29.6% · Q3 28.8% · Q4 28.6% · 4Q avg 28.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
2.3%
0.6 pts better
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 4.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
3.0%
0.1 pts better
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.5% · Q3 1.6% · Q4 3.2% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.9% |
25.5%
3.4 pts worse
|
19.8%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 28.9% · Q3 29.3% · Q4 29.3% · 4Q avg 28.9% |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
5.5%
4.6 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.8% |
86.8%
8 pts worse
|
81.7%
2.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 84.1% · Q2 81.2% · Q3 73.7% · Q4 75.0% · 4Q avg 78.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 26.7% |
15.0%
11.7 pts worse
|
12.0%
14.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.7% · Observed 25.0% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.3%
1.7 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 0.0% · Q4 4.2% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
82.2%
13.9 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.0% |
22.7%
7.7 pts better
|
23.9%
8.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 14.5% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-18 · Fire 2024-07-18
4 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-07-18 · Fire 2023-07-18
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-09-10
E · Potential for more than minimal harm
2025-09-10
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-09-29
E · Potential for more than minimal harm
2025-09-10
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-09-16
D · Potential for more than minimal harm
2024-07-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-07-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-07-18
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-07-31
E · Potential for more than minimal harm
2023-07-18
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-07-18
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-07-18
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 2023-07-20
D · Potential for more than minimal harm
2023-07-18
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 2023-07-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-10
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-17
E · Potential for more than minimal harm
2024-07-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-18
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 2024-08-16
D · Potential for more than minimal harm
2024-07-18
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 2024-08-16
D · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-01-08
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 2024-01-25
E · Potential for more than minimal harm
2023-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-18
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 2023-08-11
D · Potential for more than minimal harm
2023-07-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-18
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 2023-08-11
D · Potential for more than minimal harm
2023-07-18
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 2023-08-11
D · Potential for more than minimal harm
2023-07-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-11
C · Minimal harm
2023-07-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-08-11
Penalties and ownership
What sits behind the stars
Ownership
Park Manor Ltd Employee Stock Ownership Plan
5% Or Greater Direct Ownership Interest · Organization
Armstrong, Tom
Corporate Director · Individual
Boley, Krista
Operational/Managerial Control · Individual
Boley, Krista
Corporate Officer · Individual
Fischer, Georgiana
Corporate Director · Individual
Flygt, Thomas
Operational/Managerial Control · Individual
Haegerl, Karen
Operational/Managerial Control · Individual
Kock, Paula
Corporate Director · Individual
Preisler - Hersperger, Jill
Corporate Officer · Individual
Schultz, Sharon
Corporate Officer · Individual
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#3
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