Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Wood Aven Health and Rehabilitation
WAUSAU, WI · 82 certified beds · Last Life Safety survey April 1, 2026
CMS Certification Number 525503 · first certified January 1993
Ownership
Operated by THE ENSIGN GROUP · For profit - Limited Liability company
- New ownershipOwnership changed November 1, 2024 (change of ownership)from MARYWOOD CONVALESCENT CENTER
Position within WI
23 citations — more than 67% 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 3 citations; the earlier surveys in the window averaged 10. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens May 2027 — about 7 months from now. This facility’s last Life Safety survey was April 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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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
3 of the 23 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 23 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 | 23 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 30, 2023 | 7 |
| January 8, 2025 | 13 |
| April 1, 2026 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2025-01-08 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2026-04-01 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2026-04-01 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2026-04-01 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2025-01-08 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2025-01-08 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2025-01-08 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 1 | 2025-01-08 |
What the citations cover
- Smoke Deficiencies 10
- Services Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Miscellaneous Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Services Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 3 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 1, 2026 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 17, 2026) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (April 17, 2026) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (April 17, 2026) |
January 8, 2025 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (January 29, 2025) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (January 29, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (January 29, 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 (January 29, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 29, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 29, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 29, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (January 29, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (January 29, 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 (January 29, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (January 29, 2025) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (January 29, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 29, 2025) |
November 30, 2023 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (December 29, 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 (December 29, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (December 29, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 29, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 29, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 29, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 29, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.