Cycle 1
Health 2026-01-13 · Fire 2026-01-13
17 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Tomah, WI
Tomah Nursing And Rehab
1-star overall rating with 1-star inspections with $61,870 in total fines with 16 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1505 Butts Ave, Tomah, WI
(608) 372-3241
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
74
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atrium Centers
Operator or chain grouping
Approved since
1989-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
26 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
0.65
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.17
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.82
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,724
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.84
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.71
Baseline 21.50% · Performance 18.78% · Measure score 5.71 · Achievement 5.71 · Improvement 5.57
Healthcare-associated infections
3.41
Baseline 8.65% · Performance 7.22% · Measure score 3.41 · Achievement 2.06 · Improvement 3.41
Total nurse turnover
0.31
Baseline 71.67% · Performance 67.86% · Measure score 0.31 · Achievement 0 · Improvement 0.31
Adjusted total nurse staffing
0.9
Baseline 3.90 hours · Performance 3.33 hours · Measure score 0.9 · Achievement 0.9 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.12% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 6.02% · Lower 95% interval 6.36% |
| Discharge to community | 55.78% |
50.57%
5.2 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 53.52% · Lower 95% interval 46.04% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.15% |
95.27%
2.9 pts better
|
Numerator 53 · Denominator 54 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 54 |
| Discharge self-care score | 47.37% |
53.69%
6.3 pts worse
|
Numerator 18 · Denominator 38 |
| Discharge mobility score | 47.37% |
50.94%
3.6 pts worse
|
Numerator 18 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 9.26% |
2.29%
7 pts worse
|
Numerator 5 · Denominator 54 · Adjusted rate 8.12% |
| Healthcare-associated infections requiring hospitalization | 7.22% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 7.27% · Lower 95% interval 3.64% |
| Staff COVID-19 vaccination coverage | 10.53% |
8.2%
2.3 pts better
|
Numerator 10 · Denominator 95 |
| Staff flu vaccination coverage | 39.51% |
42%
2.5 pts worse
|
Numerator 32 · Denominator 81 |
| Discharge function score | 57.89% |
56.45%
1.4 pts better
|
Numerator 22 · Denominator 38 |
| 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 | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 14.81% |
25.2%
10.4 pts worse
|
Numerator 4 · Denominator 27 |
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 1.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.0 |
2.2
2.8 pts worse
|
1.8
3.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.0 · Observed 4.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.3% |
95.7%
5.4 pts worse
|
93.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 90.9% · Q3 89.1% · Q4 85.7% · 4Q avg 90.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.2% |
95.0%
2.8 pts worse
|
95.5%
3.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.2%
1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.3% · Q3 2.2% · Q4 2.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.4% |
5.0%
6.4 pts worse
|
11.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 15.0% · Q3 12.5% · Q4 13.3% · 4Q avg 11.4% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
4.9%
1.1 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.3% · Q3 2.5% · Q4 8.9% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.3% |
16.6%
3.3 pts better
|
19.6%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 12.5% · Q3 9.5% · Q4 12.8% · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.6% |
16.7%
8.9 pts worse
|
16.7%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 27.3% · Q3 31.0% · Q4 26.5% · 4Q avg 25.6% · 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 | 8.3% |
21.1%
12.8 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
17.3%
8.2 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 10.8% · Q3 7.5% · Q4 2.2% · 4Q avg 9.1% · 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 | 2.2% |
3.0%
0.8 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.4% · Q3 2.3% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.7% |
25.5%
10.8 pts better
|
19.8%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 16.8% · Q3 13.0% · Q4 11.1% · 4Q avg 14.7% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.5%
0.5 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.1% · Q3 2.3% · Q4 8.3% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.5% |
86.8%
10.3 pts worse
|
81.7%
5.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.3% · Q2 81.5% · Q3 72.1% · Q4 75.6% · 4Q avg 76.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
15.0%
1.8 pts better
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 12.3% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.2% |
1.3%
2.9 pts worse
|
1.6%
2.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 3.2% · Q3 2.9% · Q4 3.7% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.5% |
82.2%
18.7 pts worse
|
79.7%
16.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
22.7%
4.2 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 17.5% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-29 · Fire 2024-08-29
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-07-19 · Fire 2023-07-19
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 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
2026-01-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2026-01-27
F · Potential for more than minimal harm
2026-01-13
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
2026-01-13
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2026-01-27
E · Potential for more than minimal harm
2026-01-13
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2026-08-05
E · Potential for more than minimal harm
2026-01-13
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2026-01-27
D · Potential for more than minimal harm
2026-01-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-27
D · Potential for more than minimal harm
2026-01-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2026-01-27
C · Minimal harm
2026-01-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-27
E · Potential for more than minimal harm
2024-08-29
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 2024-09-12
E · Potential for more than minimal harm
2024-08-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-12
C · Minimal harm
2024-08-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-12
F · Potential for more than minimal harm
2023-07-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-11
F · Potential for more than minimal harm
2023-07-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-11
F · Potential for more than minimal harm
2023-07-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-11
F · Potential for more than minimal harm
2023-07-19
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 2023-08-11
D · Potential for more than minimal harm
2023-07-19
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 2023-08-11
C · Minimal harm
2023-07-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-11
C · Minimal harm
2023-07-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-05
F · Potential for more than minimal harm
2026-01-13
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 2026-02-05
F · Potential for more than minimal harm
2026-01-13
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2026-02-05
D · Potential for more than minimal harm
2026-01-13
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 2026-02-05
D · Potential for more than minimal harm
2026-01-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-05
D · Potential for more than minimal harm
2026-01-13
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2026-02-05
D · Potential for more than minimal harm
2026-01-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2026-02-05
D · Potential for more than minimal harm
2026-01-13
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2026-02-05
D · Potential for more than minimal harm
2026-01-13
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 2026-02-05
D · Potential for more than minimal harm
2026-01-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-02-05
J · Immediate jeopardy
2025-12-22
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 2026-01-09
D · Potential for more than minimal harm
2025-09-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-11-24
F · Potential for more than minimal harm
2025-06-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-11
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 2025-06-27
D · Potential for more than minimal harm
2025-06-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-25
D · Potential for more than minimal harm
2024-11-11
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 2024-11-22
F · Potential for more than minimal harm
2024-08-29
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 2024-09-19
E · Potential for more than minimal harm
2024-08-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-08-29
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 2024-09-19
D · Potential for more than minimal harm
2024-08-29
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 2024-09-19
D · Potential for more than minimal harm
2024-08-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-19
D · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-19
D · Potential for more than minimal harm
2023-11-28
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-19
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-08-11
G · Actual harm
2023-05-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-22
F · Potential for more than minimal harm
2023-05-31
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 2023-06-22
E · Potential for more than minimal harm
2023-05-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-05-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-05-31
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-22
Penalties and ownership
What sits behind the stars
$61,870
2023-05-31
Fine
Fine · fine $61,870
Fine
Ownership
Orion Operating Services LLC
5% Or Greater Direct Ownership Interest · Organization
Albright Ross, Susan
Corporate Officer · Individual
Amicus Capital Holdings Inc Esop
5% Or Greater Indirect Ownership Interest · Organization
Atrium Centers Management LLC
Operational/Managerial Control · Organization
Atrium Centers, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Bailey, Essel
Corporate Officer · Individual
Finney, Donald
Corporate Officer · Individual
Lockhart, Dennis
Corporate Director · Individual
Rocca, Michael
Corporate Officer · Individual
Shea, Brandi
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Rolling Hills Rehab Ctr
Sparta, WI
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Morrow Memorial Home
Sparta, WI
4-star overall rating with 4-star inspections with 3 recent health deficiencies
#3
Crest View Nursing Home
New Lisbon, WI
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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