Reedsburg, WI
2-star overall rating with 2-star inspections with $160,977 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1051 Clark St, Reedsburg, WI
(608) 524-7500
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
82
Certified beds
Average residents
51
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
RN hours / resident day
0.99
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.05
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.81
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.18
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.15
CMS adjusted RN staffing hours
Adjusted total hours
5.58
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
77%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
5,307
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9900
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.27
Baseline 19.73% · Performance 19.45% · Measure score 4.27 · Achievement 4.27 · Improvement 0.51
Healthcare-associated infections
4.24
Baseline 6.27% · Performance 6.57% · Measure score 4.24 · Achievement 4.24 · Improvement 0
Total nurse turnover
0.74
Performance 60.66% · Measure score 0.74 · Achievement 0.74 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.41
Baseline 4.11 hours · Performance 4.62 hours · Measure score 5.41 · Achievement 5.41 · Improvement 2.56
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.9% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 4.26% · Lower 95% interval 6.38% |
| Discharge to community | 56.16% |
50.57%
5.6 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 61.54% · Lower 95% interval 41.87% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.12% |
95.27%
1.1 pts worse
|
Numerator 48 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 24 · Denominator 44 |
| Discharge mobility score | 47.73% |
50.94%
3.2 pts worse
|
Numerator 21 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 51 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.57% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 2.56% · Lower 95% interval 3.36% |
| Staff COVID-19 vaccination coverage | 1.9% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 105 |
| Staff flu vaccination coverage | 80.32% |
42%
38.3 pts better
|
Numerator 151 · Denominator 188 |
| Discharge function score | 47.73% |
56.45%
8.7 pts worse
|
Numerator 21 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 32 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 13.51% |
25.2%
11.7 pts worse
|
Numerator 5 · Denominator 37 |
Quality measures
| 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 1.8 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.1 |
2.2
1.9 pts worse
|
1.8
2.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.1 · Observed 3.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
95.7%
2 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 97.7% · Q3 97.6% · Q4 97.7% · 4Q avg 97.7% |
| 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 | 0.6% |
3.2%
2.6 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
5.0%
3.2 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 0.0% · Q4 2.5% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
4.9%
2.4 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.0% · Q3 2.6% · Q4 0.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.1% |
16.6%
10.5 pts better
|
19.6%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 2.5% · Q3 5.1% · Q4 9.5% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
16.7%
1.7 pts better
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 16.7% · Q3 16.7% · Q4 18.8% · 4Q avg 15.0% · 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 | 28.9% |
21.1%
7.8 pts worse
|
16.3%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 32.2% · Q3 47.5% · 4Q avg 28.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.4% |
17.3%
11.1 pts worse
|
14.9%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 25.6% · Q3 44.7% · Q4 23.1% · 4Q avg 28.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
3.0%
0.1 pts better
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.5% · Q3 2.4% · Q4 2.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.4% |
25.5%
9.1 pts better
|
19.8%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 14.1% · Q3 28.4% · Q4 11.8% · 4Q avg 16.4% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.5%
2.8 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.0% · Q3 4.9% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.1% |
86.8%
3.7 pts worse
|
81.7%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 65.7% · Q2 76.7% · Q3 90.0% · Q4 93.9% · 4Q avg 83.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.6% |
15.0%
0.4 pts better
|
12.0%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 12.5% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.3%
1.4 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 6.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.4% |
82.2%
4.2 pts better
|
79.7%
6.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
22.7%
1.8 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 17.5% · Expected 20.0% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-04-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-03
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-03-31
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 2025-03-27
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-27
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-27
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-05-16
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-05-16
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-05-16
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-28
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-28
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-28
Inspection history
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-19
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-18
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-08
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 2025-04-08
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-08
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 2025-04-08
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-31
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-31
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-16
Health
Provide appropriate foot care.
Corrected 2024-05-16
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-05-16
Penalties and ownership
Fine · fine $123,000
Fine
Fine · fine $11,723
Fine
Fine · fine $26,254
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Corporate Director · Individual
W-2 Managing Employee · Individual
Nearby options
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Baraboo, WI
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