4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Monroe, WI
1-star overall rating with 1-star inspections with abuse icon flag with $67,298 in total fines with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
N3150 Wi-81, Monroe, WI
(608) 325-2171
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
96
Certified beds
Average residents
80
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-05-01
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
RN hours / resident day
0.57
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.70
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.01
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.80
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
5.45
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
7,910
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.78
Baseline 21.62% · Performance 20.14% · Measure score 2.78 · Achievement 2.78 · Improvement 2.72
Healthcare-associated infections
0.81
Baseline 5.91% · Performance 7.59% · Measure score 0.81 · Achievement 0.81 · Improvement 0
Total nurse turnover
4.08
Baseline 23.17% · Performance 46.99% · Measure score 4.08 · Achievement 4.08 · Improvement 0
Adjusted total nurse staffing
3.70
Baseline 4.69 hours · Performance 4.13 hours · Measure score 3.70 · Achievement 3.70 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.24% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 8.33% · Lower 95% interval 6.75% |
| Discharge to community | 53.07% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 50.67% · Lower 95% interval 45.39% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 96.15% |
95.27%
0.9 pts better
|
Numerator 50 · Denominator 52 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 52 |
| Discharge self-care score | 45.65% |
53.69%
8 pts worse
|
Numerator 21 · Denominator 46 |
| Discharge mobility score | 43.48% |
50.94%
7.5 pts worse
|
Numerator 20 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 3.85% |
2.29%
1.6 pts worse
|
Numerator 2 · Denominator 52 · Adjusted rate 4.03% |
| Healthcare-associated infections requiring hospitalization | 7.59% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 7.14% · Lower 95% interval 4.21% |
| Staff COVID-19 vaccination coverage | 6.74% |
8.2%
1.5 pts worse
|
Numerator 12 · Denominator 178 |
| Staff flu vaccination coverage | 51.77% |
42%
9.8 pts better
|
Numerator 117 · Denominator 226 |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 24 · Denominator 46 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.14% |
96.28%
0.9 pts better
|
Numerator 34 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 36% |
25.2%
10.8 pts better
|
Numerator 9 · Denominator 25 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.0% |
95.7%
3.7 pts worse
|
93.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 93.8% · Q3 88.2% · Q4 87.0% · 4Q avg 92.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
95.0%
3.5 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.2%
0.2 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.6% · Q3 4.4% · Q4 2.9% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.3% |
5.0%
4.3 pts worse
|
11.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 12.5% · Q3 9.5% · Q4 4.5% · 4Q avg 9.3% |
| Percentage of long-stay residents who lose too much weight | 12.0% |
4.9%
7.1 pts worse
|
5.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 12.8% · Q3 13.2% · Q4 3.6% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
16.6%
2.6 pts worse
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 20.0% · Q3 20.8% · Q4 17.9% · 4Q avg 19.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.9% |
16.7%
9.2 pts worse
|
16.7%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 25.0% · Q3 23.3% · Q4 31.0% · 4Q avg 25.9% · 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 | 32.3% |
21.1%
11.2 pts worse
|
16.3%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.3% · Q2 27.9% · Q3 23.6% · Q4 33.9% · 4Q avg 32.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.7% |
17.3%
10.4 pts worse
|
14.9%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 20.8% · Q3 26.9% · Q4 30.9% · 4Q avg 27.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.5% |
2.3%
1.2 pts worse
|
1.0%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 5.1% · Q4 4.7% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
3.0%
0.5 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.2% · Q3 1.5% · Q4 5.9% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.7% |
25.5%
3.8 pts better
|
19.8%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 17.5% · Q3 26.5% · Q4 16.7% · 4Q avg 21.7% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.5%
3.4 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 2.8% · Q4 1.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.4% |
86.8%
32.4 pts worse
|
81.7%
27.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.5% · Q2 49.0% · Q3 47.8% · Q4 54.4% · 4Q avg 54.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.0% |
15.0%
5 pts worse
|
12.0%
8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 18.0% · Expected 10.1% · 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 | 76.5% |
82.2%
5.7 pts worse
|
79.7%
3.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.1% |
22.7%
3.6 pts better
|
23.9%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 16.4% · Expected 20.4% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Rights (10 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2025-10-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-14
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-10-14
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-10-14
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-10-14
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 2025-10-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-10-14
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-10-14
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-07-30
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 2024-07-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-30
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-30
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-07-30
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 2024-07-30
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-07-30
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-04-17
Fire Safety
Install proper backup exit lighting.
Corrected 2023-04-17
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-04-17
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-17
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-19
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-19
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-04-17
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 2023-04-17
Inspection history
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 2025-08-05
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-08-26
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-26
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2025-06-27
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-28
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-28
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-28
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-28
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-11-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-01
Health
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
Corrected 2024-11-01
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-11-01
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-01
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-01
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-11-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-01
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-08
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-26
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-07-26
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 2024-07-26
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-26
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-07-26
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-26
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-26
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-26
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-03-26
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-03-26
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-03-26
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-03-26
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-03-26
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-03-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-25
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-04-05
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-04-05
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-25
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-04-05
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-04-05
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-04-05
Penalties and ownership
Payment Denial · denial start 2024-08-07 · 93 days
93 day denial
Fine · fine $41,980
Fine
Fine · fine $25,318
Fine
Payment Denial · denial start 2023-04-19 · 6 days
6 day denial
Operational/Managerial Control · Organization
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
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