Cycle 1
Health 2025-07-16 · Fire 2025-07-16
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Weston, WI
Pride Tlc Therapy And Living Campus
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
7805 Birch St, Weston, WI
(715) 298-3833
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
25
Certified beds
Average residents
18
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2013-06-18
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
2.54
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.32
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.60
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
6.47
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.87
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
6.10
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
2.05
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.42
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
2.24
CMS adjusted RN staffing hours
Adjusted total hours
5.69
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,746
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.24
Composite VBP score used to determine payment impact.
Payment multiplier
1.0091
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.08
Baseline 21.44% · Performance 20.47% · Measure score 2.08 · Achievement 2.08 · Improvement 1.70
Healthcare-associated infections
7.70
Baseline 6.08% · Performance 5.53% · Measure score 7.70 · Achievement 7.70 · Improvement 4.56
Total nurse turnover
6.49
Baseline 38.46% · Performance 37.14% · Measure score 6.49 · Achievement 6.49 · Improvement 0.47
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.68% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 157 · Observed rate 8.28% · Lower 95% interval 7.95% |
| Discharge to community | 66.39% |
50.57%
15.8 pts better
|
Better than the National Rate · Eligible stays 158 · Observed rate 68.99% · Lower 95% interval 60.78% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 70 · Denominator 70 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 70 |
| Discharge self-care score | 90.32% |
53.69%
36.6 pts better
|
Numerator 56 · Denominator 62 |
| Discharge mobility score | 82.26% |
50.94%
31.3 pts better
|
Numerator 51 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 70 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.53% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 1.15% · Lower 95% interval 3.01% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 79 |
| Staff flu vaccination coverage | 37.18% |
42%
4.8 pts worse
|
Numerator 29 · Denominator 78 |
| Discharge function score | 82.26% |
56.45%
25.8 pts better
|
Numerator 51 · Denominator 62 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 46 · Denominator 46 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 48.39% |
25.2%
23.2 pts better
|
Numerator 15 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.8%
13.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 17.6% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.3%
1.1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.6% |
82.2%
14.4 pts better
|
79.7%
16.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
22.7%
4.7 pts better
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 13.7% · Expected 18.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-08 · Fire 2024-05-08
3 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-24 · Fire 2023-05-24
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-04
F · Potential for more than minimal harm
2025-07-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-07-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-04
C · Minimal harm
2025-07-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-23
F · Potential for more than minimal harm
2024-05-08
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-06-08
F · Potential for more than minimal harm
2024-05-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-08
E · Potential for more than minimal harm
2024-05-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-08
E · Potential for more than minimal harm
2024-05-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-08
D · Potential for more than minimal harm
2024-05-08
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 2024-06-08
F · Potential for more than minimal harm
2023-05-24
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-06-20
F · Potential for more than minimal harm
2023-05-24
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-06-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-16
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-16
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-16
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-08-16
F · Potential for more than minimal harm
2024-05-08
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 2024-06-08
D · Potential for more than minimal harm
2024-05-08
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 2024-06-08
D · Potential for more than minimal harm
2024-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-08
Penalties and ownership
What sits behind the stars
Ownership
Wanxiang America Real Estate Group, LLC
5% Or Greater Direct Ownership Interest · Organization
Johnson Conway, Sally
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Rennes Health And Rehab Center-Weston
Weston, WI
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
North Central Health Care
Wausau, WI
2-star overall rating with 2-star inspections with $13,627 in total fines with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Amethyst Health Of Wausau
Wausau, WI
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $96,300 in total fines with 24 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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