Cycle 1
Health 2025-05-22 · Fire 2025-05-22
18 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Richland Center, WI
Pine Valley Community Village
2-star overall rating with 1-star inspections with $97,311 in total fines with 18 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
25951 Circle View Lane, Richland Center, WI
(608) 647-2138
Overall
2 / 5
CMS overall stars
Health inspections
1 / 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
80
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.02
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.42
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
4.50
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
3.82
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.14
CMS adjusted RN staffing hours
Adjusted total hours
5.00
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
887
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.49
Composite VBP score used to determine payment impact.
Payment multiplier
1.0174
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.81
Baseline 18.82% · Performance 20.13% · Measure score 2.81 · Achievement 2.81 · Improvement 0
Healthcare-associated infections
7.89
Baseline 7.08% · Performance 5.48% · Measure score 7.89 · Achievement 7.89 · Improvement 7.19
Total nurse turnover
7.52
Baseline 26.51% · Performance 32.93% · Measure score 7.52 · Achievement 7.52 · Improvement 0
Adjusted total nurse staffing
6.77
Baseline 4.07 hours · Performance 5.01 hours · Measure score 6.77 · Achievement 6.77 · Improvement 4.96
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.86% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 4.8% · Lower 95% interval 5.68% |
| Discharge to community | 49.11% |
50.57%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 101 · Observed rate 46.53% · Lower 95% interval 42.1% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 77 · Denominator 77 |
| Falls with major injury | 1.3% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 77 |
| Discharge self-care score | 54.24% |
53.69%
0.6 pts better
|
Numerator 32 · Denominator 59 |
| Discharge mobility score | 47.46% |
50.94%
3.5 pts worse
|
Numerator 28 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 1.3% |
2.29%
1 pts better
|
Numerator 1 · Denominator 77 · Adjusted rate 1.47% |
| Healthcare-associated infections requiring hospitalization | 5.48% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 1.14% · Lower 95% interval 2.58% |
| Staff COVID-19 vaccination coverage | 12.07% |
8.2%
3.9 pts better
|
Numerator 21 · Denominator 174 |
| Staff flu vaccination coverage | 73.68% |
42%
31.7 pts better
|
Numerator 126 · Denominator 171 |
| Discharge function score | 66.1% |
56.45%
9.6 pts better
|
Numerator 39 · Denominator 59 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 60% |
25.2%
34.8 pts better
|
Numerator 18 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
2.2
1.3 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
95.7%
2.5 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.0% · Q3 100.0% · Q4 96.5% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
95.0%
1.4 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.2%
1.3 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 6.0% · Q3 3.4% · Q4 1.8% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
5.0%
4.5 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
4.9%
0.9 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 9.3% · Q3 6.1% · Q4 3.9% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.4% |
16.6%
9.2 pts better
|
19.6%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 8.7% · Q3 7.3% · Q4 3.8% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.2% |
16.7%
10.5 pts worse
|
16.7%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 28.6% · Q3 24.4% · Q4 26.7% · 4Q avg 27.2% · 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 | 12.7% |
21.1%
8.4 pts better
|
16.3%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q4 8.2% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
17.3%
0.6 pts better
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 15.6% · Q3 16.7% · Q4 13.5% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
2.3%
1.3 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
3.0%
0.6 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.4% · Q3 0.0% · Q4 3.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
25.5%
1.4 pts better
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 22.4% · Q3 13.0% · Q4 34.5% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.5%
1 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.5% · Q3 4.0% · Q4 6.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
86.8%
10.7 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 96.2% · Q3 95.7% · Q4 100.0% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
15.0%
0.8 pts better
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 12.7% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.3%
1.1 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.6% · Q4 5.7% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
82.2%
12.1 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.6% |
22.7%
4.1 pts better
|
23.9%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 16.5% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-03 · Fire 2024-04-03
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-01-25 · Fire 2023-01-25
1 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-22
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-22
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-22
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-22
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 2025-06-20
D · Potential for more than minimal harm
2025-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-20
E · Potential for more than minimal harm
2024-04-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-04-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-04-03
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-04-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-23
D · Potential for more than minimal harm
2023-01-25
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-01-27
D · Potential for more than minimal harm
2023-01-25
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 2023-02-13
D · Potential for more than minimal harm
2023-01-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-30
D · Potential for more than minimal harm
2023-01-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-01-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-27
D · Potential for more than minimal harm
2023-01-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-14
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 2026-01-29
J · Immediate jeopardy
2025-07-22
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-07-03
F · Potential for more than minimal harm
2025-07-22
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-08-06
F · Potential for more than minimal harm
2025-07-22
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-08-06
F · Potential for more than minimal harm
2025-07-22
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-08-06
F · Potential for more than minimal harm
2025-07-22
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-08-06
F · Potential for more than minimal harm
2025-07-22
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-08-06
G · Actual harm
2025-06-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-21
F · Potential for more than minimal harm
2025-05-22
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 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
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 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-13
J · Immediate jeopardy
2025-03-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-31
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-31
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-04-18
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 2024-04-22
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 2024-04-22
F · Potential for more than minimal harm
2023-01-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-23
Penalties and ownership
What sits behind the stars
$22,925
2025-07-22
Fine
Fine · fine $22,925
Fine
$74,386
2025-03-31
Fine
Fine · fine $74,386
Fine
Ownership
County Of Richland
5% Or Greater Direct Ownership Interest · Organization
County Of Richland
Operational/Managerial Control · Organization
Paulus, Brittany
Operational/Managerial Control · Individual
Paulus, Brittany
Corporate Director · Individual
Sidhu, Sarfraz
Operational/Managerial Control · Individual
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