Cycle 1
Health 2025-07-17 · Fire 2025-07-17
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Clintonville, WI
The Pines Post Acute And Memory Care
3-star overall rating with 3-star inspections with $18,400 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1625 E Main St, Clintonville, WI
(715) 823-3135
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
43
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1992-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,164
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9989
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
7.42
Baseline 52.17% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 6.40
Adjusted total nurse staffing
1.71
Baseline 3.38 hours · Performance 3.56 hours · Measure score 1.71 · Achievement 1.71 · Improvement 0.28
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 76 |
| Staff flu vaccination coverage | 80.41% |
42%
38.4 pts better
|
Numerator 78 · Denominator 97 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
95.7%
3.1 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.7% · Q3 97.4% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
95.0%
2.8 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| 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 · Q1 0.0% · Q2 2.3% · Q3 2.6% · Q4 5.7% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.9% |
5.0%
11.9 pts worse
|
11.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 19.5% · Q3 5.9% · Q4 9.4% · 4Q avg 16.9% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
4.9%
1.5 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 0.0% · Q3 6.9% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
16.6%
2 pts worse
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 18.8% · Q3 17.2% · Q4 19.2% · 4Q avg 18.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.3% |
16.7%
8.6 pts worse
|
16.7%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 26.9% · Q3 29.2% · Q4 26.1% · 4Q avg 25.3% · 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 | 10.3% |
21.1%
10.8 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.7% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.7% |
17.3%
9.6 pts better
|
14.9%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 0.0% · Q3 11.5% · Q4 8.7% · 4Q avg 7.7% · 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 | 1.9% |
3.0%
1.1 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 5.7% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.1% |
25.5%
0.6 pts worse
|
19.8%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 25.4% · Q3 31.1% · Q4 22.4% · 4Q avg 26.1% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.5%
2.9 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.2% · Q3 3.7% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.0% |
86.8%
0.2 pts better
|
81.7%
5.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.8% · Q3 86.1% · Q4 76.5% · 4Q avg 87.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
82.2%
9.5 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-15 · Fire 2024-05-15
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-05-10 · Fire 2023-05-10
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-07-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-07-17
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 2025-08-21
E · Potential for more than minimal harm
2025-07-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-07-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-08-08
F · Potential for more than minimal harm
2024-05-15
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-06-07
F · Potential for more than minimal harm
2024-05-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-07
E · Potential for more than minimal harm
2024-05-15
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-06-07
E · Potential for more than minimal harm
2024-05-15
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 2024-06-07
E · Potential for more than minimal harm
2024-05-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-15
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-06-07
E · Potential for more than minimal harm
2023-05-10
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 2023-06-05
E · Potential for more than minimal harm
2023-05-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-17
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 2025-08-08
E · Potential for more than minimal harm
2025-07-17
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 2025-08-08
D · Potential for more than minimal harm
2025-07-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-17
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-17
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 2025-08-08
D · Potential for more than minimal harm
2025-07-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-08
G · Actual harm
2025-06-19
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 2025-07-04
D · Potential for more than minimal harm
2025-06-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-07-04
J · Immediate jeopardy
2025-05-01
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-05-01
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-28
E · Potential for more than minimal harm
2024-05-15
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 2024-06-10
E · Potential for more than minimal harm
2024-05-15
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 2024-06-10
D · Potential for more than minimal harm
2024-05-15
F690 · Quality of Life and Care Deficiencies
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 2024-06-10
D · Potential for more than minimal harm
2024-05-15
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 2024-06-10
D · Potential for more than minimal harm
2024-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-10
D · Potential for more than minimal harm
2023-05-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-10
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 2023-06-09
D · Potential for more than minimal harm
2023-05-10
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 2023-06-09
Penalties and ownership
What sits behind the stars
$18,400
2025-06-19
Fine
Fine · fine $18,400
Fine
Ownership
Gateway Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Bell, Cody
Operational/Managerial Control · Individual
Bell, Cody
W-2 Managing Employee · Individual
Burnam, Soon
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Greentree Health And Rehabilitation Center
Clintonville, WI
2-star overall rating with 3-star inspections with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Shawano Health Services
Shawano, WI
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Evergreen Health Services
Shawano, WI
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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