Cycle 1
Health 2025-02-12 · Fire 2025-02-12
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Stevens Point, WI
Timber Ridge Health and Rehabilitation
5-star overall rating with 3-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
825 Whiting Ave, Stevens Point, WI
(715) 346-1374
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
33
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-05-01
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
1.14
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.91
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.85
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.48
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.80
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.17
CMS adjusted RN staffing hours
Adjusted total hours
4.97
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,201
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.88
Composite VBP score used to determine payment impact.
Payment multiplier
1.0141
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.91
Baseline 19.09% · Performance 17.77% · Measure score 7.91 · Achievement 7.91 · Improvement 5.93
Healthcare-associated infections
2.61
Baseline 5.75% · Performance 7.05% · Measure score 2.61 · Achievement 2.61 · Improvement 0
Total nurse turnover
7.42
Baseline 38.64% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 3.35
Adjusted total nurse staffing
5.61
Baseline 4.77 hours · Performance 4.67 hours · Measure score 5.61 · Achievement 5.61 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.08% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 6.67% · Lower 95% interval 6.48% |
| Discharge to community | 65.12% |
50.57%
14.6 pts better
|
Better than the National Rate · Eligible stays 86 · Observed rate 65.12% · Lower 95% interval 54.36% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 48 · Denominator 48 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 48 |
| Discharge self-care score | 56.1% |
53.69%
2.4 pts better
|
Numerator 23 · Denominator 41 |
| Discharge mobility score | 48.78% |
50.94%
2.2 pts worse
|
Numerator 20 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 2.08% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 48 · Adjusted rate 2.67% |
| Healthcare-associated infections requiring hospitalization | 7.06% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 5.45% · Lower 95% interval 3.83% |
| Staff COVID-19 vaccination coverage | 2.63% |
8.2%
5.6 pts worse
|
Numerator 3 · Denominator 114 |
| Staff flu vaccination coverage | 69.37% |
42%
27.4 pts better
|
Numerator 77 · Denominator 111 |
| Discharge function score | 70.73% |
56.45%
14.3 pts better
|
Numerator 29 · Denominator 41 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 40% |
25.2%
14.8 pts better
|
Numerator 12 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 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 | 6.5% |
3.2%
3.3 pts worse
|
3.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.7% · Q3 4.8% · Q4 4.0% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
5.0%
0.1 pts better
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q4 0.0% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
4.9%
3.6 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.8% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
16.6%
7 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 9.1% · Q4 13.6% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
16.7%
11 pts better
|
16.7%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 5.0% · 4Q avg 5.7% · 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 | 13.2% |
21.1%
7.9 pts better
|
16.3%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
17.3%
7.8 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 10.0% · Q4 5.0% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.5% |
2.3%
3.2 pts worse
|
1.0%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 4.4% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.1% |
3.0%
6.1 pts worse
|
1.7%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 13.6% · Q3 0.0% · Q4 0.0% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.0% |
25.5%
5.5 pts better
|
19.8%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 15.5% · 4Q avg 20.0% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.5%
1.9 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 9.0% · Q3 3.6% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
86.8%
11.8 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 98.1% · Q3 98.4% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.3% |
15.0%
2.3 pts worse
|
12.0%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 16.0% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.3%
0.1 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 2.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
82.2%
14.2 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.4% |
22.7%
9.3 pts better
|
23.9%
10.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 12.0% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-06 · Fire 2023-12-06
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-10-20 · Fire 2022-10-20
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-12
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-02-12
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-02-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-02-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-15
F · Potential for more than minimal harm
2025-02-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-02-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2025-02-12
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 2025-04-09
D · Potential for more than minimal harm
2025-02-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-01
F · Potential for more than minimal harm
2023-12-06
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-01-18
F · Potential for more than minimal harm
2023-12-06
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-01-04
F · Potential for more than minimal harm
2023-12-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-18
F · Potential for more than minimal harm
2023-12-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
F · Potential for more than minimal harm
2023-12-06
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-01-22
E · Potential for more than minimal harm
2023-12-06
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-06
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 2024-01-18
D · Potential for more than minimal harm
2023-12-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-06
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2024-01-18
F · Potential for more than minimal harm
2022-10-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-25
F · Potential for more than minimal harm
2022-10-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-25
E · Potential for more than minimal harm
2022-10-20
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-11-25
D · Potential for more than minimal harm
2022-10-20
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-11-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-12
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 2025-03-31
E · Potential for more than minimal harm
2025-02-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-10
E · Potential for more than minimal harm
2025-02-12
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 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-18
D · Potential for more than minimal harm
2025-02-12
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-18
D · Potential for more than minimal harm
2024-12-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-12-03
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 2025-01-28
D · Potential for more than minimal harm
2024-11-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-11-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-19
D · Potential for more than minimal harm
2023-12-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-04
D · Potential for more than minimal harm
2022-10-20
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2022-11-15
Penalties and ownership
What sits behind the stars
Ownership
County Of Portage
5% Or Greater Direct Ownership Interest · Organization
Mcdonald, Marcia
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Stevens Point Health Services
Stevens Point, WI
1-star overall rating with 2-star inspections with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Edenbrook Of Wisconsin Rapids
Wisconsin Rapids, WI
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Wisconsin Rapids Health Services
Wisconsin Rapids, WI
1-star overall rating with 1-star inspections with $99,626 in total fines with 20 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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