Cycle 1
Health 2025-01-23 · Fire 2025-01-23
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Waunakee, WI
Waunakee Valley Senior Living
3-star overall rating with 3-star inspections with $41,501 in total fines with 5 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
801 Klein Dr, Waunakee, WI
(608) 849-5016
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
94
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing
LPN hours / resident day
0.67
Licensed practical nurse staffing
Aide hours / resident day
2.02
Nurse aide staffing
Weekend hours
2.77
Weekend nurse staffing
RN turnover
77%
Annual RN turnover
Total nurse turnover
54%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.6
0.7 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.2
0.4 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
95.0%
3 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| 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 |
| Percentage of long-stay residents who have depressive symptoms | 5.7% |
5.0%
0.7 pts worse
|
11.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.3% |
4.9%
2.6 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.8% |
16.6%
7.8 pts better
|
19.6%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 20.0% |
16.7%
3.3 pts worse
|
16.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.0% |
21.1%
11.1 pts better
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.4% |
17.3%
7.9 pts better
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.0%
3 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.8% |
25.5%
1.3 pts worse
|
19.8%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
5.5%
3.9 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.8%
13.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
15.0%
3.2 pts better
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.7% |
82.2%
15.5 pts better
|
79.7%
18 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
22.7%
1.7 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-08 · Fire 2024-01-08
14 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-12-08 · Fire 2022-12-08
18 health deficiencies
Top issue: Infection Control (5 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-23
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-01-23
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 2025-02-17
E · Potential for more than minimal harm
2025-01-23
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-01-23
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-01-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-23
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-23
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-23
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-17
F · Potential for more than minimal harm
2024-01-08
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-02-01
F · Potential for more than minimal harm
2024-01-08
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-02-01
E · Potential for more than minimal harm
2024-01-08
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-02-01
E · Potential for more than minimal harm
2024-01-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-01
E · Potential for more than minimal harm
2024-01-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-01
E · Potential for more than minimal harm
2024-01-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-08
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 2024-02-15
D · Potential for more than minimal harm
2024-01-08
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-08
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-02-01
F · Potential for more than minimal harm
2022-12-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-12-08
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-12-08
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-12-08
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 2023-01-10
E · Potential for more than minimal harm
2022-12-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-12-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-12-08
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-08
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 2023-01-10
D · Potential for more than minimal harm
2022-12-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-08
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 2023-01-10
D · Potential for more than minimal harm
2022-12-08
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-01-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-23
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-23
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-23
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 2025-02-21
J · Immediate jeopardy
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 2024-10-30
E · Potential for more than minimal harm
2024-11-11
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-11
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 2024-12-12
J · Immediate jeopardy
2024-08-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-08-06
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 2024-09-03
E · Potential for more than minimal harm
2024-08-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-01-08
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 2024-02-05
E · Potential for more than minimal harm
2024-01-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-08
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 2024-02-05
D · Potential for more than minimal harm
2024-01-08
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 2024-02-05
D · Potential for more than minimal harm
2024-01-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-08
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2024-02-05
G · Actual harm
2022-12-08
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 2023-01-10
G · Actual harm
2022-12-08
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-12-08
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 2023-01-10
F · Potential for more than minimal harm
2022-12-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-12-08
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-12-08
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-12-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-12-08
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-12-08
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-08
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-08
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 2023-01-10
D · Potential for more than minimal harm
2022-12-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-08
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-08
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-01-10
C · Minimal harm
2022-12-08
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-01-10
Penalties and ownership
What sits behind the stars
$24,700
2024-11-11
Fine
Fine · fine $24,700
Fine
$16,801
2024-08-06
Fine
Fine · fine $16,801
Fine
$0
2024-08-06
Payment Denial
Payment Denial · denial start 2024-09-04 · 44 days
44 day denial
Ownership
Ahr Trs Wisconsin Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
American Healthcare Reit Holdings LP
5% Or Greater Indirect Ownership Interest · Organization
American Healthcare Reit Inc
5% Or Greater Indirect Ownership Interest · Organization
Continental Merger Sub LLC
5% Or Greater Indirect Ownership Interest · Organization
Corbin, Kathy
Operational/Managerial Control · Individual
Fightmaster, Lisa
Operational/Managerial Control · Individual
Hoekstra, Ryan
Operational/Managerial Control · Individual
Prosky, Danny
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Middleton Village Nursing And Rehab
Middleton, WI
1-star overall rating with 1-star inspections with $84,573 in total fines with 18 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Capitol Lakes Health Center
Madison, WI
3-star overall rating with 2-star inspections with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Oakwood Village East Health And Rehab Center
Madison, WI
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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