Superior, WI

Villa Marina Health And Rehab Ctr

5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

35 N 28th St, Superior, WI

(715) 392-3300

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

72

Certified beds

Average residents

66

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1997-03-01

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

1.05

Registered nurse staffing · state 0.97 · national 0.68

LPN hours / resident day

0.27

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.51

Nurse aide staffing · state 2.59 · national 2.35

Total nurse hours

3.82

All reported nurse hours · state 4.20 · national 3.89

Licensed hours

1.31

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.31

Weekend nurse staffing · state 3.72 · national 3.43

Weekend RN hours

0.81

Weekend registered nurse coverage · state 0.66 · national 0.47

Physical therapist

0.11

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

1.16

CMS adjusted RN staffing hours

Adjusted total hours

4.22

CMS adjusted total nurse staffing hours

Case-mix index

1.24

Higher values indicate more complex resident acuity

RN turnover

6%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

32%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,395

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

40.15

Composite VBP score used to determine payment impact.

Payment multiplier

0.9931

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.42

Baseline 19.37% · Performance 19.38% · Measure score 4.42 · Achievement 4.42 · Improvement 0

Healthcare-associated infections

0

Baseline 5.97% · Performance 8.25% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

9.20

Performance 26.09% · Measure score 9.20 · Achievement 9.20 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

2.45

Baseline 3.81 hours · Performance 3.77 hours · Measure score 2.45 · Achievement 2.45 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.3%	10.72% 0.4 pts better	No Different than the National Rate · Eligible stays 85 · Observed rate 9.41% · Lower 95% interval 6.98%
Discharge to community	49.99%	50.57% 0.6 pts worse	No Different than the National Rate · Eligible stays 79 · Observed rate 45.57% · Lower 95% interval 36.63%
Medicare spending per beneficiary	1.12	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 93 · Denominator 93
Falls with major injury	1.08%	0.77% 0.3 pts worse	Numerator 1 · Denominator 93
Discharge self-care score	69.23%	53.69% 15.5 pts better	Numerator 45 · Denominator 65
Discharge mobility score	67.69%	50.94% 16.8 pts better	Numerator 44 · Denominator 65
Pressure ulcers or injuries, new or worsened	1.08%	2.29% 1.2 pts better	Numerator 1 · Denominator 93 · Adjusted rate 1.29%
Healthcare-associated infections requiring hospitalization	8.25%	7.12% 1.1 pts worse	No Different than the National Rate · Eligible stays 52 · Observed rate 11.54% · Lower 95% interval 4.79%
Staff COVID-19 vaccination coverage	3.88%	8.2% 4.3 pts worse	Numerator 5 · Denominator 129
Staff flu vaccination coverage	58.9%	42% 16.9 pts better	Numerator 86 · Denominator 146
Discharge function score	72.31%	56.45% 15.9 pts better	Numerator 47 · Denominator 65
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 29 · Denominator 29
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 37 · Denominator 37
Resident COVID-19 vaccinations up to date	60.38%	25.2% 35.2 pts better	Numerator 32 · Denominator 53

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.7	1.6 0.1 pts worse	1.9 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.7	2.2 0.5 pts better	1.8 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.7 · Used in QM five-star
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	2.2%	3.2% 1 pts better	3.3% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.8% · Q3 3.7% · Q4 1.9% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.9%	5.0% 4.1 pts better	11.4% 10.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9%
Percentage of long-stay residents who lose too much weight	0.5%	4.9% 4.4 pts better	5.4% 4.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 0.0% · 4Q avg 0.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	16.2%	16.6% 0.4 pts better	19.6% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 14.3% · Q3 18.8% · Q4 16.3% · 4Q avg 16.2%
Percentage of long-stay residents who received an antipsychotic medication	8.9%	16.7% 7.8 pts better	16.7% 7.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 9.8% · Q3 9.8% · Q4 7.7% · 4Q avg 8.9% · 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	22.3%	21.1% 1.2 pts worse	16.3% 6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 23.6% · Q3 25.6% · Q4 18.3% · 4Q avg 22.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.5%	17.3% 1.2 pts worse	14.9% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 10.4% · Q3 22.9% · Q4 18.8% · 4Q avg 18.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.2%	2.3% 0.1 pts better	1.0% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.4% · Q3 2.3% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.3%	3.0% 0.7 pts better	1.7% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 5.6% · Q3 0.0% · Q4 1.9% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	25.7%	25.5% 0.2 pts worse	19.8% 5.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 20.3% · Q3 26.6% · Q4 23.7% · 4Q avg 25.7%
Percentage of long-stay residents with pressure ulcers	0.4%	5.5% 5.1 pts better	5.1% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.0%	86.8% 12.2 pts better	81.7% 17.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.8% · Q4 97.6% · 4Q avg 99.0%
Percentage of short-stay residents who had an outpatient emergency department visit	18.8%	15.0% 3.8 pts worse	12.0% 6.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 20.4% · Expected 12.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.1%	1.3% 1.8 pts worse	1.6% 1.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 3.6% · Q4 3.8% · 4Q avg 3.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.2%	82.2% 11 pts better	79.7% 13.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.7%	22.7% 3 pts worse	23.9% 1.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 28.6% · Expected 26.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-18 · Fire 2025-09-18

3 health deficiencies

Top issue: Infection Control (1 deficiency)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-07-24 · Fire 2024-07-24

9 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-07-12 · Fire 2023-07-12

1 health deficiencies

Top issue: Infection Control (1 deficiency)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-09-18

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-10-07

D · Potential for more than minimal harm 2025-09-18

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2025-10-07

F · Potential for more than minimal harm 2023-07-12

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-08-25

F · Potential for more than minimal harm 2023-07-12

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-08-25

E · Potential for more than minimal harm 2023-07-12

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-08-25

E · Potential for more than minimal harm 2023-07-12

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-08-25

D · Potential for more than minimal harm 2023-07-12

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-08-25

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-09-18

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 2025-11-21

E · Potential for more than minimal harm 2025-09-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-11-10

D · Potential for more than minimal harm 2025-09-18

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-10-07

F · Potential for more than minimal harm 2024-07-24

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 2024-09-06

F · Potential for more than minimal harm 2024-07-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-06

E · Potential for more than minimal harm 2024-07-24