Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Timber Ridge Health and Rehabilitation
Stevens Point, WI · 48 certified beds · Last Life Safety survey May 6, 2026
CMS Certification Number 525611 · first certified May 1997
Ownership
Operated by THE ENSIGN GROUP · For profit - Corporation
- New ownershipOwnership changed February 1, 2026 (change of ownership)from COUNTY OF PORTAGE
Position within WI
21 citations — more than 62% 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 4 citations; the earlier surveys in the window averaged 8.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens June 2027 — about 9 months from now. This facility’s last Life Safety survey was May 2026. 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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2 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
4 of the 21 citations on file are 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)
3 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 21 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 | 21 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 6, 2023 | 9 |
| February 12, 2025 | 8 |
| May 6, 2026 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-05-06 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2026-05-06 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2025-02-12 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2023-12-06 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2025-02-12 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 1 | 2025-02-12 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2025-02-12 |
| K-0161 | Use approved construction type or materials. | 1 | 2026-05-06 |
What the citations cover
- Smoke Deficiencies 9
- Emergency Preparedness Deficiencies 4
- Miscellaneous Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Emergency Preparedness Deficiencies | 4 |
| Miscellaneous Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Services Deficiencies | 2 |
| Egress Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 6, 2026 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (June 1, 2026) |
| 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 (June 1, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 1, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 1, 2026) |
February 12, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (May 9, 2025) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (April 29, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (March 14, 2025) |
| 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 (April 9, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 15, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 9, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (April 1, 2025) |
December 6, 2023 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (January 18, 2024) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (January 4, 2024) |
| 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 (January 18, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 18, 2024) |
| K-0364 | Install properly constructed windows in hallway walls or doors. | Deficient, Provider has date of correction (January 18, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (January 18, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (January 22, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (January 18, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.