Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MIDDLE RIVER HEALTH AND REHABILITATION CENTER
SOUTH RANGE, WI · 86 certified beds · Last Life Safety survey August 14, 2025
CMS Certification Number 525408 · first certified April 1987
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
- Ownership changed April 16, 2024 (change of ownership)from ASPEN HEALTH AND REHAB LLC
Position within WI
34 citations — more than 93% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 11 citations; the earlier surveys in the window averaged 11.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: September 2026 to November 2026. This facility’s last Life Safety survey was August 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 34 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 34 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 34 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 7, 2023 | 19 |
| June 13, 2024 | 4 |
| August 14, 2025 | 11 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 3 | 2025-08-14 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-08-14 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2025-08-14 |
| K-0923 | Have proper medical gas storage and administration areas. | 2 | 2025-08-14 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2025-08-14 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2025-08-14 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-08-14 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-08-14 |
What the citations cover
- Smoke Deficiencies 16
- Egress Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Services Deficiencies 4
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 16 |
| Egress Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Services Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 14, 2025 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | No revisit needed |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (September 12, 2025) |
June 13, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Waiver has been granted (July 5, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (July 5, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 5, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 5, 2024) |
June 7, 2023 — 19 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (June 29, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Waiver has been granted (July 18, 2023) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Waiver has been granted (March 13, 2024) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (July 7, 2023) |
| K-0271 | Have exits that are accessible at all times. | Waiver has been granted (March 13, 2024) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (July 7, 2023) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (July 7, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (July 7, 2023) |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (July 7, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 7, 2023) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (July 7, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (July 18, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 18, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Waiver has been granted (March 13, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Waiver has been granted (March 13, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (July 7, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (July 7, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 7, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (July 7, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.