7Risk Axes

National percentile · lower = less risk · staffing gap is context only (not in composite)

How we calculate
SeverityElevated

85th national percentile — 11.9% high-severity citations

ChronicityElevated

71th national percentile — 12 repeat citations

Staffing integrityClean

None on file

Fire safetyElevated

23 citations

Weekend staffing dropLow

6th national percentile — 8.2%

Contract staff shareElevated

92th national percentile — 19.8%

Clinical trendElevated

70th national percentile — 2/5 measures worsened

Staffing gapElevated

Reported 4.31 vs expected 4.97 · −0.66 hr/res/day

Recent Health Violations

Health inspection citations from official Medicare records

42 citations on file
F-0883
D
Develop and implement policies and procedures for flu and pneumonia vacc…
Minimal Harm

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey date: Mar 24, 2026 · Isolated — no actual harm with potential for more
F-0887
D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 …
Minimal Harm

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.

Survey date: Mar 24, 2026 · Isolated — no actual harm with potential for more
F-0609
D
Timely report suspected abuse, neglect, or theft and report the results …
Minimal Harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey date: Aug 4, 2025 · Isolated — no actual harm with potential for more
F-0678
K
Provide basic life support, including CPR, prior to the arrival of emerg…
Actual Harm

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Survey date: Aug 4, 2025 · Pattern — immediate jeopardy

Recent Fire Safety Violations

Fire safety inspection citations from official Medicare records

23 citations on file
F-0132
E
Meet requirements for outpatient facilities located next to inpatient fa…
Potential Harm

Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

Survey date: Sep 18, 2025 · Pattern — no actual harm with potential for more
F-0293
D
Have properly located and lighted "Exit" signs
Minimal Harm

Have properly located and lighted "Exit" signs.

Survey date: Sep 18, 2025 · Isolated — no actual harm with potential for more
F-0321
D
Ensure that special areas are constructed so that walls can resist fire …
Minimal Harm

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Survey date: Sep 18, 2025 · Isolated — no actual harm with potential for more
F-0353
E
Inspect, test, and maintain automatic sprinkler systems
Potential Harm

Inspect, test, and maintain automatic sprinkler systems.

Survey date: Sep 18, 2025 · Pattern — no actual harm with potential for more

Better Nearby Options

Within 25 km · sorted by overall risk percentile

Full nearby list
Facility
CMS
Risk %ile
Tier
MONROE HEALTH SERVICES
1.5 km · MONROE, WI
★★★★
CMS
53th
Risk %ile
Similar risk