Cycle 1
Health 2024-09-18 · Fire 2024-09-18
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Dodgeville, WI
Upland Hills Nursing And Rehab
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
800 Compassion Way, Dodgeville, WI
(608) 930-7600
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
44
Certified beds
Average residents
28
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-01-01
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.83
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.12
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.29
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.24
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
4.58
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.42
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
2.03
CMS adjusted RN staffing hours
Adjusted total hours
5.80
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,063
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.33
Composite VBP score used to determine payment impact.
Payment multiplier
1.0155
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.18
Baseline 19.62% · Performance 19.03% · Measure score 5.18 · Achievement 5.18 · Improvement 1.77
Healthcare-associated infections
5.19
Baseline 5.73% · Performance 6.29% · Measure score 5.19 · Achievement 5.19 · Improvement 0
Total nurse turnover
4.98
Baseline 23.64% · Performance 43.33% · Measure score 4.98 · Achievement 4.98 · Improvement 0
Adjusted total nurse staffing
8.79
Baseline 5.63 hours · Performance 5.58 hours · Measure score 8.79 · Achievement 8.79 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.4% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 4.76% · Lower 95% interval 5.7% |
| Discharge to community | 53.69% |
50.57%
3.1 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 50.94% · Lower 95% interval 42.04% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.25% |
95.27%
3 pts better
|
Numerator 56 · Denominator 57 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 57 |
| Discharge self-care score | 48.15% |
53.69%
5.5 pts worse
|
Numerator 26 · Denominator 54 |
| Discharge mobility score | 57.41% |
50.94%
6.5 pts better
|
Numerator 31 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 57 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.29% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 0% · Lower 95% interval 3.17% |
| Staff COVID-19 vaccination coverage | 8.06% |
8.2%
0.1 pts worse
|
Numerator 10 · Denominator 124 |
| Staff flu vaccination coverage | 87.88% |
42%
45.9 pts better
|
Numerator 116 · Denominator 132 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 36 · Denominator 54 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.43% |
25.2%
3.8 pts worse
|
Numerator 6 · Denominator 28 |
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 | 96.0% |
95.0%
1 pts better
|
95.5%
0.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.2%
0.8 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.0% · Q3 4.2% · Q4 3.8% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
5.0%
2.8 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 3.8% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 12.1% |
4.9%
7.2 pts worse
|
5.4%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 17.4% · Q3 13.6% · Q4 13.6% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.5% |
16.6%
1.9 pts worse
|
19.6%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 16.7% · Q3 13.6% · Q4 18.2% · 4Q avg 18.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.0% |
16.7%
0.7 pts better
|
16.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q3 15.0% · Q4 23.8% · 4Q avg 16.0% · 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 | 15.9% |
21.1%
5.2 pts better
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.9% |
17.3%
6.4 pts better
|
14.9%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 12.5% · Q3 13.6% · Q4 4.5% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.5% |
2.3%
4.2 pts worse
|
1.0%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 9.9% · Q3 9.0% · Q4 0.0% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.1% |
3.0%
3.1 pts worse
|
1.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.3% · Q3 8.3% · Q4 0.0% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.7% |
25.5%
3.2 pts worse
|
19.8%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 46.6% · Q3 12.9% · Q4 19.8% · 4Q avg 28.7% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
5.5%
0.5 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 8.3% · Q3 7.8% · Q4 0.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
86.8%
9.1 pts better
|
81.7%
14.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 94.3% · Q3 93.3% · Q4 100.0% · 4Q avg 95.9% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 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 | 74.3% |
82.2%
7.9 pts worse
|
79.7%
5.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-26 · Fire 2023-07-26
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-06-08 · Fire 2022-06-08
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-18
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 2024-10-18
D · Potential for more than minimal harm
2024-09-18
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-18
F · Potential for more than minimal harm
2023-07-26
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-07-26
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-07-26
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-07-26
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 2023-08-21
D · Potential for more than minimal harm
2023-07-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-21
D · Potential for more than minimal harm
2022-06-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-06-13
D · Potential for more than minimal harm
2022-06-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-06-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-09-18
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 2024-10-15
D · Potential for more than minimal harm
2024-09-18
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 2024-10-15
G · Actual harm
2024-07-10
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 2024-08-05
F · Potential for more than minimal harm
2023-07-26
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 2023-08-21
D · Potential for more than minimal harm
2023-07-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-21
Penalties and ownership
What sits behind the stars
Ownership
Dunn, Aaron
Operational/Managerial Control · Individual
Fischer, Sandra
Corporate Officer · Individual
Goninen, Jay
Corporate Director · Individual
Hebgen, Lynn
Operational/Managerial Control · Individual
Holter, Alan
Corporate Officer · Individual
Karls, Krisann
Operational/Managerial Control · Individual
Kinonen, Christopher
Corporate Director · Individual
Laufenberg, Bradley
Corporate Director · Individual
Marx, Troy
Operational/Managerial Control · Individual
Massey, James
Corporate Officer · Individual
Moyer, Danielle
Operational/Managerial Control · Individual
Nondorf, Kyle
Corporate Director · Individual
O'neil, Rachel
Operational/Managerial Control · Individual
Potterton, Andrea
Corporate Director · Individual
Pustina, Arthur
Operational/Managerial Control · Individual
Pustina, Arthur
Corporate Director · Individual
Schnedler, Lisa
Corporate Director · Individual
Stroud, Allison
Corporate Director · Individual
Thronson, John
Corporate Officer · Individual
Wysocki, Scott
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Mineral Point Health Services
Mineral Point, WI
3-star overall rating with 4-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Greenway Manor
Spring Green, WI
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Ingleside Manor
Mount Horeb, WI
1-star overall rating with 1-star inspections with Special Focus status with $50,343 in total fines with 49 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
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