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
Chain footprint
125 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 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
0.50
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.77
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.16
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
0.46
CMS adjusted RN staffing hours
Adjusted total hours
2.94
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
77%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,796
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9956
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.81
Baseline 20.03% · Performance 20.13% · Measure score 2.81 · Achievement 2.81 · Improvement 0
Healthcare-associated infections
7.97
Baseline 4.90% · Performance 5.45% · Measure score 7.97 · Achievement 7.97 · Improvement 0
Total nurse turnover
4.90
Performance 43.64% · Measure score 4.90 · Achievement 4.90 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.38
Baseline 3.96 hours · Performance 3.47 hours · Measure score 1.38 · Achievement 1.38 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.72% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 6.72% · Lower 95% interval 6.55% |
| Discharge to community | 64.92% |
50.57%
14.4 pts better
|
Better than the National Rate · Eligible stays 115 · Observed rate 61.74% · Lower 95% interval 55.47% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 111 · Denominator 111 |
| Falls with major injury | 1.8% |
0.77%
1 pts worse
|
Numerator 2 · Denominator 111 |
| Discharge self-care score | 70.45% |
53.69%
16.8 pts better
|
Numerator 62 · Denominator 88 |
| Discharge mobility score | 75% |
50.94%
24.1 pts better
|
Numerator 66 · Denominator 88 |
| Pressure ulcers or injuries, new or worsened | 1.8% |
2.29%
0.5 pts better
|
Numerator 2 · Denominator 111 · Adjusted rate 1.53% |
| Healthcare-associated infections requiring hospitalization | 5.45% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 1.22% · Lower 95% interval 2.66% |
| Staff COVID-19 vaccination coverage | 0.79% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 127 |
| Staff flu vaccination coverage | 9.22% |
42%
32.8 pts worse
|
Numerator 19 · Denominator 206 |
| Discharge function score | 76.14% |
56.45%
19.7 pts better
|
Numerator 67 · Denominator 88 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 75 · Denominator 75 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 50.94% |
25.2%
25.7 pts better
|
Numerator 27 · Denominator 53 |
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 · Adjusted 2.3 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| 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 · Adjusted 2.6 · Observed 2.1 · Expected 1.3 · 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 | 98.0% |
95.0%
3 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| 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 4.5% · Q2 0.0% · Q3 2.2% · Q4 2.1% · 4Q avg 2.2% · Used in QM five-star |
| 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 · Q1 10.5% · Q2 7.5% · Q3 2.6% · Q4 2.3% · 4Q avg 5.7% |
| 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 · Q1 0.0% · Q2 5.9% · Q3 0.0% · Q4 2.9% · 4Q avg 2.3% |
| 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 · Q1 9.4% · Q2 5.7% · Q3 5.9% · Q4 13.9% · 4Q avg 8.8% |
| 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 · Q1 20.8% · Q2 25.0% · Q3 17.2% · Q4 17.2% · 4Q avg 20.0% · 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 | 10.0% |
21.1%
11.1 pts better
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.0% · Used in QM five-star |
| 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 · Q1 20.0% · Q2 6.2% · Q3 3.1% · Q4 8.8% · 4Q avg 9.4% · 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 | 0.0% |
3.0%
3 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 26.8% |
25.5%
1.3 pts worse
|
19.8%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 34.5% · Q3 35.5% · Q4 9.4% · 4Q avg 26.8% |
| 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 · Q1 1.4% · Q2 1.3% · Q3 2.7% · Q4 1.2% · 4Q avg 1.6% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · Adjusted 11.8% · Observed 11.1% · Expected 10.5% · Used in QM five-star |
| 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 · Q1 1.7% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| 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 · 4Q avg 97.7% |
| 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 · Adjusted 24.4% · Observed 25.0% · Expected 24.4% · Used in QM five-star |
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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