Cycle 1
Health 2026-01-15 · Fire 2026-01-15
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Stoughton, WI
Skaalen Nursing And Rehabilitation Center
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
400 N Morris St, Stoughton, WI
(608) 873-5651
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
50
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-06-01
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
Hours and turnover
RN hours / resident day
1.30
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.37
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.29
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
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.47
CMS adjusted RN staffing hours
Adjusted total hours
4.20
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,531
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.22
Composite VBP score used to determine payment impact.
Payment multiplier
1.0031
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.14
Baseline 18.77% · Performance 18.12% · Measure score 7.14 · Achievement 7.14 · Improvement 3.21
Healthcare-associated infections
6.05
Baseline 6.58% · Performance 6.03% · Measure score 6.05 · Achievement 6.05 · Improvement 3
Total nurse turnover
2.63
Performance 52.94% · Measure score 2.63 · Achievement 2.63 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.86
Baseline 4.86 hours · Performance 4.18 hours · Measure score 3.86 · Achievement 3.86 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.6% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 6.48% · Lower 95% interval 6.15% |
| Discharge to community | 60.66% |
50.57%
10.1 pts better
|
Better than the National Rate · Eligible stays 98 · Observed rate 60.2% · Lower 95% interval 51.95% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 126 · Denominator 126 |
| Falls with major injury | 0.79% |
0.77%
About the same
|
Numerator 1 · Denominator 126 |
| Discharge self-care score | 40.37% |
53.69%
13.3 pts worse
|
Numerator 44 · Denominator 109 |
| Discharge mobility score | 36.7% |
50.94%
14.2 pts worse
|
Numerator 40 · Denominator 109 |
| Pressure ulcers or injuries, new or worsened | 2.38% |
2.29%
0.1 pts worse
|
Numerator 3 · Denominator 126 · Adjusted rate 2.46% |
| Healthcare-associated infections requiring hospitalization | 6.03% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 2.9% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 10.98% |
8.2%
2.8 pts better
|
Numerator 18 · Denominator 164 |
| Staff flu vaccination coverage | 37.3% |
42%
4.7 pts worse
|
Numerator 69 · Denominator 185 |
| Discharge function score | 44.04% |
56.45%
12.4 pts worse
|
Numerator 48 · Denominator 109 |
| 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 | 98.63% |
96.28%
2.3 pts better
|
Numerator 72 · Denominator 73 |
| Resident COVID-19 vaccinations up to date | 73.44% |
25.2%
48.2 pts better
|
Numerator 47 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.9 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.2
0.8 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.8 · 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 | 93.5% |
95.0%
1.5 pts worse
|
95.5%
2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.1% |
3.2%
2.9 pts worse
|
3.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 7.5% · Q3 4.7% · Q4 2.4% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
5.0%
2.3 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 2.6% · Q4 5.3% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
4.9%
3.3 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 3.1% · Q4 0.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
16.6%
4.1 pts better
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 12.1% · Q3 12.5% · Q4 9.4% · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.7% |
16.7%
About the same
|
16.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 22.2% · Q3 16.7% · Q4 14.8% · 4Q avg 16.7% · 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 | 20.1% |
21.1%
1 pts better
|
16.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
17.3%
About the same
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 24.2% · Q3 6.2% · Q4 28.1% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 12.2% |
2.3%
9.9 pts worse
|
1.0%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 15.4% · Q3 9.4% · Q4 7.8% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
3.0%
1.8 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.0% |
25.5%
2.5 pts better
|
19.8%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 33.2% · Q3 27.9% · Q4 14.8% · 4Q avg 23.0% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.5%
2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.5% · Q3 3.5% · Q4 1.7% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
86.8%
11.6 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 97.6% · Q3 100.0% · Q4 98.6% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.8% |
15.0%
4.8 pts worse
|
12.0%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 18.0% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.3%
1.8 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.8% · Q3 2.4% · Q4 2.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.7% |
82.2%
5.5 pts better
|
79.7%
8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
22.7%
1.2 pts worse
|
23.9%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 21.3% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-10 · Fire 2024-09-10
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-05-23 · Fire 2023-05-23
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2026-01-15
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-13
F · Potential for more than minimal harm
2024-09-10
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-10
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-10
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 2024-10-10
E · Potential for more than minimal harm
2024-09-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-09-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-09-10
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-10
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 2024-10-10
D · Potential for more than minimal harm
2024-09-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-10
F · Potential for more than minimal harm
2023-05-23
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-06-23
E · Potential for more than minimal harm
2023-05-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-23
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 2023-06-23
D · Potential for more than minimal harm
2023-05-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-23
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-09-10
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 2024-10-10
E · Potential for more than minimal harm
2024-09-10
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2024-10-10
F · Potential for more than minimal harm
2023-05-23
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 2023-06-23
F · Potential for more than minimal harm
2023-05-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-23
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-23
Penalties and ownership
What sits behind the stars
Ownership
Agni, Guirish
Operational/Managerial Control · Individual
Bienfang, Tayler
Operational/Managerial Control · Individual
Carley, Jacqueline
Corporate Officer · Individual
Krentz, Kristian
Corporate Officer · Individual
Schellhorn, Maggie
Operational/Managerial Control · Individual
Skaalen Retirement Services, Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Complete Care at Nazareth LLC
Stoughton, WI
2-star overall rating with 2-star inspections with $32,443 in total fines with 7 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Edgerton Care Center, Inc
Edgerton, WI
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Evansville Manor Nursing And Rehab, LLC
Evansville, WI
1-star overall rating with 1-star inspections with $51,776 in total fines with 27 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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