Cycle 1
Health 2025-07-23 · Fire 2025-07-23
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Pigeon Falls, WI
Pigeon Falls Hcc
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
13197 Church St, Pigeon Falls, WI
(715) 983-2293
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
37
Certified beds
Average residents
37
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-01-01
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
0.66
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,680
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.83
Composite VBP score used to determine payment impact.
Payment multiplier
1.0098
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
9.46
Baseline 46.88% · Performance 25.00% · Measure score 9.46 · Achievement 9.46 · Improvement 9
Adjusted total nurse staffing
1.50
Baseline 3.41 hours · Performance 3.51 hours · Measure score 1.50 · Achievement 1.50 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · 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 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.52% |
8.2%
1.7 pts worse
|
Numerator 3 · Denominator 46 |
| Staff flu vaccination coverage | 64.06% |
42%
22.1 pts better
|
Numerator 41 · Denominator 64 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · 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 |
|---|---|---|---|---|
| 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 0.5 · Expected 0.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.2
0.6 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 1.8 · Expected 1.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
95.7%
3.6 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| 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 | 4.3% |
3.2%
1.1 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.8% · Q3 2.9% · Q4 8.8% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.4% |
5.0%
0.4 pts worse
|
11.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 8.3% · Q3 6.1% · Q4 0.0% · 4Q avg 5.4% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
4.9%
1.8 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 6.2% · Q4 3.3% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.3% |
16.6%
3.3 pts better
|
19.6%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 11.4% · Q3 12.5% · Q4 18.8% · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.5% |
16.7%
4.2 pts better
|
16.7%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 14.3% · Q3 10.7% · Q4 12.0% · 4Q avg 12.5% · 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 | 16.1% |
21.1%
5 pts better
|
16.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 8.1% · Q3 26.7% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.2% |
17.3%
8.9 pts worse
|
14.9%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 12.1% · Q3 36.7% · Q4 41.4% · 4Q avg 26.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
2.3%
1.6 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.0%
3 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 28.1% |
25.5%
2.6 pts worse
|
19.8%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 33.7% · Q3 36.6% · Q4 20.4% · 4Q avg 28.1% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.5%
5.5 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
86.8%
8.9 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 95.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-30 · Fire 2024-05-30
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-05-10 · Fire 2023-05-10
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-07-23
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-07-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-07-23
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-07-29
C · Minimal harm
2025-07-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-29
E · Potential for more than minimal harm
2024-05-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-31
F · Potential for more than minimal harm
2023-05-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-05-10
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 2023-05-31
E · Potential for more than minimal harm
2023-05-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-05-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-31
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-23
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 2025-08-15
D · Potential for more than minimal harm
2025-07-23
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-23
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 2025-08-15
D · Potential for more than minimal harm
2025-07-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-15
F · Potential for more than minimal harm
2023-05-10
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 2023-05-31
Penalties and ownership
What sits behind the stars
Ownership
County Of Trempealeau
5% Or Greater Direct Ownership Interest · Organization
Deetz, Jerry
Corporate Director · Individual
Glaunert, Lori
Corporate Officer · Individual
Hammel, Katrina
Operational/Managerial Control · Individual
Thesing, Rosemarie
Operational/Managerial Control · Individual
Nearby options
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4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
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2-star overall rating with 2-star inspections with $59,085 in total fines with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
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5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
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