Cycle 1
Health 2025-01-09 · Fire 2025-01-09
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Sun Prairie, WI
Sun Prairie Senior Living
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
228 W Main St, Sun Prairie, WI
(608) 837-5959
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
42
Certified beds
Average residents
34
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
1984-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 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
1.09
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.92
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.05
CMS adjusted RN staffing hours
Adjusted total hours
3.72
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,829
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9887
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.32
Baseline 19.52% · Performance 19.43% · Measure score 4.32 · Achievement 4.32 · Improvement 0
Healthcare-associated infections
6.75
Baseline 6.18% · Performance 5.82% · Measure score 6.75 · Achievement 6.75 · Improvement 2.56
Total nurse turnover
0
Performance 67.86% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.89
Baseline 5.02 hours · Performance 3.90 hours · Measure score 2.89 · Achievement 2.89 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.59% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 8.2% · Lower 95% interval 7.02% |
| Discharge to community | 53.68% |
50.57%
3.1 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 51.72% · Lower 95% interval 42.76% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.52% |
95.27%
2.2 pts better
|
Numerator 118 · Denominator 121 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 121 |
| Discharge self-care score | 55.32% |
53.69%
1.6 pts better
|
Numerator 52 · Denominator 94 |
| Discharge mobility score | 61.7% |
50.94%
10.8 pts better
|
Numerator 58 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 121 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.82% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 1.72% · Lower 95% interval 2.9% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 62 |
| Staff flu vaccination coverage | 12.73% |
42%
29.3 pts worse
|
Numerator 14 · Denominator 110 |
| Discharge function score | 69.15% |
56.45%
12.7 pts better
|
Numerator 65 · Denominator 94 |
| Transfer of health information to provider | 96.43% |
95.95%
0.5 pts better
|
Numerator 27 · Denominator 28 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 72 · Denominator 72 |
| Resident COVID-19 vaccinations up to date | 52.94% |
25.2%
27.7 pts better
|
Numerator 36 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
95.7%
0.5 pts better
|
93.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 95.0% · Q3 95.0% · Q4 96.0% · 4Q avg 96.2% |
| 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 | 2.5% |
3.2%
0.7 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 8.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
5.0%
1.1 pts better
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · Q4 4.5% · 4Q avg 3.9% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
4.9%
2.8 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.0% |
16.6%
14.6 pts better
|
19.6%
17.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.2% |
16.7%
5.5 pts worse
|
16.7%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.2% · 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 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.6% |
17.3%
1.3 pts worse
|
14.9%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.6% · 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 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.0%
3 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.7% |
25.5%
5.2 pts worse
|
19.8%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.7% |
| 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 · Q2 2.6% · Q3 0.0% · Q4 4.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.9% |
86.8%
3.1 pts better
|
81.7%
8.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.1% · Q2 90.4% · Q3 89.7% · Q4 93.2% · 4Q avg 89.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
15.0%
3.7 pts better
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 11.8% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.7% |
82.2%
7.5 pts better
|
79.7%
10 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
22.7%
1.1 pts better
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 22.4% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2022-09-22 · Fire 2022-09-22
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-09
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-02-09
E · Potential for more than minimal harm
2025-01-09
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-01-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-09
E · Potential for more than minimal harm
2025-01-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-09
E · Potential for more than minimal harm
2025-01-09
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2025-02-09
D · Potential for more than minimal harm
2025-01-09
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 2025-02-09
D · Potential for more than minimal harm
2025-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-09
D · Potential for more than minimal harm
2025-01-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-09
F · Potential for more than minimal harm
2023-11-30
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-12-22
F · Potential for more than minimal harm
2023-11-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-11-30
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-11-30
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-11-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-11-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-11-30
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-12-12
E · Potential for more than minimal harm
2023-11-30
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 2023-12-22
D · Potential for more than minimal harm
2023-11-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-22
E · Potential for more than minimal harm
2022-09-22
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-03-03
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 2025-03-17
F · Potential for more than minimal harm
2025-01-09
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-02-03
F · Potential for more than minimal harm
2025-01-09
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 2025-02-03
F · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-09
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 2025-02-03
D · Potential for more than minimal harm
2025-01-09
F584 · Resident Rights Deficiencies
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 2025-02-03
D · Potential for more than minimal harm
2025-01-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-09
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 2025-02-03
D · Potential for more than minimal harm
2025-01-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-02-03
G · Actual harm
2023-11-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-22
F · Potential for more than minimal harm
2023-11-30
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 2023-12-22
F · Potential for more than minimal harm
2023-11-30
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-11-30
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 2023-12-22
D · Potential for more than minimal harm
2023-11-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-22
F · Potential for more than minimal harm
2022-09-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-22
E · Potential for more than minimal harm
2022-09-22
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-10-22
D · Potential for more than minimal harm
2022-09-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-10-22
D · Potential for more than minimal harm
2022-09-22
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 2022-10-22
Penalties and ownership
What sits behind the stars
Ownership
Ahr Trs Wisconsin Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
American Healthcare Reit Holdings LP
5% Or Greater Indirect Ownership Interest · Organization
American Healthcare Reit Inc
5% Or Greater Indirect Ownership Interest · Organization
Barney, Leigh
Operational/Managerial Control · Individual
Continental Merger Sub LLC
5% Or Greater Indirect Ownership Interest · Organization
Corbin, Kathy
W-2 Managing Employee · Individual
Fightmaster, Lisa
W-2 Managing Employee · Individual
Oborn, Raymond
Corporate Officer · Individual
Prosky, Danny
Corporate Officer · Individual
Reierson, Brenda
W-2 Managing Employee · Individual
Trilogy Management Services LLC
Operational/Managerial Control · Organization
Willhite, Gabriel
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Avina of Sun Prairie
Sun Prairie, WI
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Oakwood Village East Health And Rehab Center
Madison, WI
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Oak Park Nursing And Rehab Center
Madison, WI
1-star overall rating with 1-star inspections with 24 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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