Cycle 1
Health 2025-01-08 · Fire 2025-01-08
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Wausau, WI
Wood Aven Health and Rehabilitation
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
1821 N 4th Ave, Wausau, WI
(715) 675-9451
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1993-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.08
Registered nurse staffing
LPN hours / resident day
0.66
Licensed practical nurse staffing
Aide hours / resident day
2.25
Nurse aide staffing
Weekend hours
3.34
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.2
1.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
95.7%
1.8 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.2%
0.2 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
5.0%
0.2 pts worse
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.7% |
4.9%
0.2 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.1% |
16.6%
7.5 pts better
|
19.6%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 17.8% |
16.7%
1.1 pts worse
|
16.7%
1.1 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 | 22.6% |
21.1%
1.5 pts worse
|
16.3%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
17.3%
1.7 pts worse
|
14.9%
4.1 pts worse
|
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 | 2.6% |
3.0%
0.4 pts better
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.6% |
25.5%
1.1 pts worse
|
19.8%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.5%
2.2 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.6% |
82.2%
15.4 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
22.7%
2 pts better
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
2 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-12-08 · Fire 2022-12-08
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-08
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-01-29
F · Potential for more than minimal harm
2025-01-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-29
F · Potential for more than minimal harm
2025-01-08
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-01-29
F · Potential for more than minimal harm
2025-01-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-29
F · Potential for more than minimal harm
2025-01-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-29
F · Potential for more than minimal harm
2025-01-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-29
F · Potential for more than minimal harm
2025-01-08
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-01-29
F · Potential for more than minimal harm
2025-01-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-29
E · Potential for more than minimal harm
2025-01-08
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 2025-01-29
E · Potential for more than minimal harm
2025-01-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-29
E · Potential for more than minimal harm
2025-01-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-29
E · Potential for more than minimal harm
2025-01-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-29
E · Potential for more than minimal harm
2023-11-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-29
E · Potential for more than minimal harm
2023-11-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-30
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-29
F · Potential for more than minimal harm
2022-12-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-08
E · Potential for more than minimal harm
2022-12-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-01-08
E · Potential for more than minimal harm
2022-12-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-08
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 2023-01-08
E · Potential for more than minimal harm
2022-12-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-01-08
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 2023-01-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-23
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 2026-01-15
D · Potential for more than minimal harm
2025-03-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-15
G · Actual harm
2025-01-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-27
F · Potential for more than minimal harm
2025-01-08
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 2025-01-27
D · Potential for more than minimal harm
2025-01-08
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-01-27
D · Potential for more than minimal harm
2023-11-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-30
Penalties and ownership
What sits behind the stars
Ownership
Gateway Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Brauer, Amy
Corporate Officer · Individual
Burnam, Soon
Corporate Officer · Individual
Jorgensen, David
Corporate Officer · Individual
Nichols, Steven
Operational/Managerial Control · Individual
Sato, Ami
Corporate Officer · Individual
Spaulding, Jared
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Amethyst Health Of Wausau
Wausau, WI
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $96,300 in total fines with 24 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Wausau Manor Health Services
Wausau, WI
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
North Central Health Care
Wausau, WI
2-star overall rating with 2-star inspections with $13,627 in total fines with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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