Cycle 1
Health 2024-09-18 · Fire 2024-09-18
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
De Pere, WI
Rennes Health and Rehab Center-De Pere
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
200 S Ninth St, De Pere, WI
(920) 336-5680
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
137
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Rennes Group
Operator or chain grouping
Approved since
1995-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 5 overall / 4 health / 5 staffing / 4 quality stars
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
1.19
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.80
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.61
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.15
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.88
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.18
CMS adjusted RN staffing hours
Adjusted total hours
4.57
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,394
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.03
Composite VBP score used to determine payment impact.
Payment multiplier
1.0122
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.96
Baseline 17.71% · Performance 18.20% · Measure score 6.96 · Achievement 6.96 · Improvement 0
Healthcare-associated infections
5.98
Baseline 4.98% · Performance 6.05% · Measure score 5.98 · Achievement 5.98 · Improvement 0
Total nurse turnover
5.69
Baseline 39.01% · Performance 40.41% · Measure score 5.69 · Achievement 5.69 · Improvement 0
Adjusted total nurse staffing
4.18
Baseline 4.14 hours · Performance 4.27 hours · Measure score 4.18 · Achievement 4.18 · Improvement 0.25
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.67% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 306 · Observed rate 10.13% · Lower 95% interval 7.97% |
| Discharge to community | 75.81% |
50.57%
25.2 pts better
|
Better than the National Rate · Eligible stays 296 · Observed rate 73.31% · Lower 95% interval 70.72% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 208 · Denominator 208 |
| Falls with major injury | 0.96% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 208 |
| Discharge self-care score | 23.3% |
53.69%
30.4 pts worse
|
Numerator 41 · Denominator 176 |
| Discharge mobility score | 44.32% |
50.94%
6.6 pts worse
|
Numerator 78 · Denominator 176 |
| Pressure ulcers or injuries, new or worsened | 0.96% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 208 · Adjusted rate 0.97% |
| Healthcare-associated infections requiring hospitalization | 6.05% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 163 · Observed rate 4.29% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 5.5% |
8.2%
2.7 pts worse
|
Numerator 17 · Denominator 309 |
| Staff flu vaccination coverage | 97.7% |
42%
55.7 pts better
|
Numerator 382 · Denominator 391 |
| Discharge function score | 25% |
56.45%
31.5 pts worse
|
Numerator 44 · Denominator 176 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 140 · Denominator 140 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 48% |
25.2%
22.8 pts better
|
Numerator 48 · Denominator 100 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.6
1 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.2
1.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 1.9% |
3.2%
1.3 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 3.2% · Q4 1.5% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
5.0%
4.6 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 1.5% |
4.9%
3.4 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
16.6%
1 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 14.9% · Q3 16.3% · Q4 14.3% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
16.7%
5.8 pts better
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 11.9% · Q3 9.5% · Q4 13.6% · 4Q avg 10.9% · 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 | 22.0% |
21.1%
0.9 pts worse
|
16.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 19.1% · Q3 18.1% · Q4 16.7% · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
17.3%
3.4 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 20.0% · Q3 13.0% · Q4 28.3% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
2.3%
0.9 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 3.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
3.0%
1.4 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.6% · Q4 3.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.5% |
25.5%
3 pts worse
|
19.8%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.7% · Q2 20.6% · Q3 27.9% · Q4 30.8% · 4Q avg 28.5% |
| Percentage of long-stay residents with pressure ulcers | 0.6% |
5.5%
4.9 pts better
|
5.1%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
86.8%
12.9 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.5% · Q4 99.5% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
15.0%
2.4 pts better
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 11.9% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.4% · Q3 1.2% · Q4 0.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.0% |
82.2%
16.8 pts better
|
79.7%
19.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
22.7%
1.7 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 21.4% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-16 · Fire 2023-08-16
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-09-15 · Fire 2022-09-15
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-13
E · Potential for more than minimal harm
2024-09-18
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-09-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-13
E · Potential for more than minimal harm
2024-09-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-09-18
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2024-10-14
D · Potential for more than minimal harm
2023-08-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-16
E · Potential for more than minimal harm
2022-09-15
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 2022-09-16
E · Potential for more than minimal harm
2022-09-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-11-14
E · Potential for more than minimal harm
2022-09-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-09-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-09-15
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-09-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-22
F585 · Resident Rights Deficiencies
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 2025-01-30
E · Potential for more than minimal harm
2024-09-18
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 2024-10-14
E · Potential for more than minimal harm
2024-09-18
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 2024-10-14
D · Potential for more than minimal harm
2024-09-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-14
D · Potential for more than minimal harm
2023-10-24
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 2023-11-13
F · Potential for more than minimal harm
2023-08-16
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 2023-09-07
E · Potential for more than minimal harm
2023-08-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-07
E · Potential for more than minimal harm
2023-08-16
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 2023-09-07
D · Potential for more than minimal harm
2023-08-16
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-09-07
F · Potential for more than minimal harm
2022-09-15
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 2022-10-07
E · Potential for more than minimal harm
2022-09-15
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 2022-10-07
D · Potential for more than minimal harm
2022-09-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-07
Penalties and ownership
What sits behind the stars
Ownership
Rennes, Debra
5% Or Greater Direct Ownership Interest · Individual
Rennes, Timothy
5% Or Greater Direct Ownership Interest · Individual
Lange, Robert
W-2 Managing Employee · Individual
Schingick, Nicole
Corporate Officer · Individual
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#3
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