2 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Oshkosh, WI
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
725 Butler Ave, Oshkosh, WI
(920) 237-6300
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
168
Certified beds
Average residents
93
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
1.14
Registered nurse staffing
LPN hours / resident day
0.55
Licensed practical nurse staffing
Aide hours / resident day
3.02
Nurse aide staffing
Weekend hours
4.37
Weekend nurse staffing
RN turnover
31%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
95.7%
3.4 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
95.0%
0.3 pts better
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.2%
1.9 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
5.0%
4.7 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.1% |
4.9%
0.8 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.1% |
16.6%
4.5 pts worse
|
19.6%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 11.7% |
16.7%
5 pts better
|
16.7%
5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 2.1% |
0.1%
2 pts worse
|
0.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.3% |
21.1%
5.2 pts worse
|
16.3%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
17.3%
0.3 pts worse
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 8.0% |
2.3%
5.7 pts worse
|
1.0%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
3.0%
0.1 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.1% |
25.5%
4.4 pts better
|
19.8%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
5.5%
2.7 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
86.8%
10 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.0% |
15.0%
11 pts better
|
12.0%
8 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.3%
1.4 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
82.2%
14.2 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.1% |
22.7%
13.6 pts better
|
23.9%
14.8 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-16
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-05-16
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-05-21
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-16
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 2025-05-16
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-03-31
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-31
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-03-08
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-03-08
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-31
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-31
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-13
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 2023-03-13
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 2023-03-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-13
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-16
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-16
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-15
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-03-15
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-15
Penalties and ownership
W-2 Managing Employee · Individual
Contracted Managing Employee · Individual
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4-star overall rating with 4-star inspections with 3 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
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