Cycle 1
Health 2025-05-14 · Fire 2025-05-14
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Hayward, WI
Water's Edge
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
11040 North State Rd 77, Hayward, WI
(715) 934-4300
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
50
Certified beds
Average residents
41
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-11-01
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
0.86
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.18
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.95
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.99
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.04
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.68
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
4.58
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,218
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9938
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.03
Performance 20.03% · Measure score 3.03 · Achievement 3.03 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.93
Performance 6.66% · Measure score 3.93 · Achievement 3.93 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.58
Baseline 39.22% · Performance 49.06% · Measure score 3.58 · Achievement 3.58 · Improvement 0
Adjusted total nurse staffing
5.80
Baseline 4.42 hours · Performance 4.73 hours · Measure score 5.80 · Achievement 5.80 · Improvement 1.75
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.09% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 0% · Lower 95% interval 5.69% |
| Discharge to community | 36.18% |
50.57%
14.4 pts worse
|
Worse than the National Rate · Eligible stays 33 · Observed rate 24.24% · Lower 95% interval 24.19% |
| Medicare spending per beneficiary | 0.6 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 28 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | 9.52% |
53.69%
44.2 pts worse
|
Numerator 2 · Denominator 21 |
| Discharge mobility score | 19.05% |
50.94%
31.9 pts worse
|
Numerator 4 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 28 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.66% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 3.33% · Lower 95% interval 3.19% |
| Staff COVID-19 vaccination coverage | 8.96% |
8.2%
0.8 pts better
|
Numerator 19 · Denominator 212 |
| Staff flu vaccination coverage | 93.53% |
42%
51.5 pts better
|
Numerator 159 · Denominator 170 |
| Discharge function score | 28.57% |
56.45%
27.9 pts worse
|
Numerator 6 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · 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 8 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.2
0.1 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
95.7%
2.1 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.1% · Q4 94.7% · 4Q avg 97.8% |
| 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 0.0% · Q2 0.0% · Q3 2.9% · Q4 5.3% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.8% |
5.0%
0.2 pts better
|
11.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 6.5% · Q4 8.3% · 4Q avg 4.8% |
| 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 6.9% · Q2 13.8% · Q3 12.9% · Q4 14.3% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
16.6%
1.6 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 10.3% · Q3 18.8% · Q4 13.9% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.2% |
16.7%
9.5 pts better
|
16.7%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 10.0% · Q3 4.5% · Q4 9.5% · 4Q avg 7.2% · 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 | 15.3% |
21.1%
5.8 pts better
|
16.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.7% |
17.3%
11.4 pts worse
|
14.9%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 24.1% · Q3 38.7% · Q4 27.3% · 4Q avg 28.7% · 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 | 6.9% |
3.0%
3.9 pts worse
|
1.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 10.0% · Q3 12.1% · Q4 2.7% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
25.5%
0.5 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 28.9% · Q3 22.4% · Q4 25.4% · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.5%
2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.9% · Q3 2.9% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.7% |
86.8%
6.9 pts better
|
81.7%
12 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 95.5% · Q4 100.0% · 4Q avg 93.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
15.0%
2 pts better
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 12.0% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.3%
1.7 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.9% |
22.7%
12.8 pts better
|
23.9%
14 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 8.0% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-24 · Fire 2024-04-24
1 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-04-05 · Fire 2023-04-05
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-14
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-05-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-05-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-30
C · Minimal harm
2025-05-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-30
E · Potential for more than minimal harm
2024-04-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-10
F · Potential for more than minimal harm
2023-04-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-03
Inspection history
Recent health citations
G · Actual harm
2025-08-08
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 2025-09-04
F · Potential for more than minimal harm
2025-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-14
D · Potential for more than minimal harm
2025-05-14
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-06-14
F · Potential for more than minimal harm
2024-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-16
D · Potential for more than minimal harm
2023-04-05
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 2023-04-21
Penalties and ownership
What sits behind the stars
Ownership
Regional Enterprises Inc
5% Or Greater Direct Ownership Interest · Organization
Beirl, Luke
Operational/Managerial Control · Individual
Beirl, Luke
Corporate Officer · Individual
Bowman, Alan
Operational/Managerial Control · Individual
Courtright, Martha
Operational/Managerial Control · Individual
Dumonseau, Kent
Operational/Managerial Control · Individual
Dumonseau, Kent
Corporate Officer · Individual
Dunlap, Sabrina
Corporate Director · Individual
Eckes, Kylah
Corporate Director · Individual
Gardner, Katrina
Corporate Director · Individual
Garrett, John
Corporate Director · Individual
Helenius, Hilary
Operational/Managerial Control · Individual
Henck, Anna
Operational/Managerial Control · Individual
Hoban, Richard
Corporate Director · Individual
Iverson, Christine
Corporate Director · Individual
Jokinen, Thomas
Corporate Director · Individual
Keller, Joy
Operational/Managerial Control · Individual
Kuchinka, Sam
Corporate Director · Individual
Leadingchoice Network LLC
Operational/Managerial Control · Organization
Lindsay, Aindrea
Operational/Managerial Control · Individual
Maanum, Scott
Operational/Managerial Control · Individual
Manning, Amanda
Operational/Managerial Control · Individual
Mikula, Dani
Corporate Director · Individual
Miller, Debra
Operational/Managerial Control · Individual
Pearson, Taylor
Corporate Director · Individual
Piecuch, Debra
Operational/Managerial Control · Individual
Schraufnagel, Patricia
Corporate Director · Individual
Setzke, Richard
Corporate Director · Individual
Sheehan, Heather
Operational/Managerial Control · Individual
Signorelli, Joseph
Corporate Director · Individual
Skar, Anna
Operational/Managerial Control · Individual
Stangret, Amanda
Operational/Managerial Control · Individual
Thompson, Dodson
Corporate Director · Individual
Thrasher, Michelle
Operational/Managerial Control · Individual
Tumas, Aistis
Corporate Director · Individual
Wegener, David
Operational/Managerial Control · Individual
Wickman, Tyler
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Hayward Health Services
Hayward, WI
4-star overall rating with 4-star inspections with $12,649 in total fines with 3 recent health deficiencies
#2
Dove Healthcare - Spooner
Spooner, WI
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Ashland Health Services
Ashland, WI
4-star overall rating with 4-star inspections with $19,988 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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