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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D5 | E3 | F9 |
| Minimal | A· | B· | C6 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Jun 10, 2026 | Fire safety | Fire Safety Standard | 1 | Potential harm | — | Open → |
| Jun 10, 2026 | Health | Health Standard | 1 | Potential harm | — | Open → |
| May 21, 2025 | Fire safety | Fire Safety Standard | 6 | Potential harm | — | Open → |
| May 21, 2025 | Health | Health Complaint, Health Standard | 5 | Potential harm | — | Open → |
| Apr 4, 2024 | Fire safety | Fire Safety Standard | 8 | Potential harm | — | Open → |
| Apr 4, 2024 | Health | Health Standard | 2 | Potential harm | — | Open → |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D5 | E3 | F9 |
| Minimal | A· | B· | C6 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jun 10, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 10, 2026 | |
| Jun 10, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jul 10, 2026 | |
| May 21, 2025 | K-0324 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Gundersen Lutheran Health System Inc | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Aug 1, 2020 |
| Bellin Gundersen Health System Inc | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | Nov 30, 2022 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Gundersen Lutheran Health System Inc | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Aug 1, 2020 |
| Bellin Gundersen Health System Inc | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | Nov 30, 2022 |
| Bellin Gundersen Health System Inc | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Nov 30, 2022 |
| Gundersen Lutheran Health System Inc | Organization | Operational / managerial control |
Coordinates as published by CMS.
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 245487 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 245487 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety |
| F · Potential harm Widespread |
| Corrected Jul 11, 2025 |
| May 21, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 31, 2025 |
| May 21, 2025 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 10, 2025 |
| May 21, 2025 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 13, 2025 |
| May 21, 2025 | F-0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jul 31, 2025 | Complaint |
| May 21, 2025 | F-0699 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 13, 2025 | Complaint |
| May 21, 2025 | F-0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jul 31, 2025 |
| May 21, 2025 | F-0726 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Jul 31, 2025 |
| May 21, 2025 | E-0035 | Provide family notifications of emergency plan. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Jul 31, 2025 |
| May 21, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Jun 30, 2025 |
| May 21, 2025 | F-0909 | Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Environmental Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Jul 31, 2025 |
| Apr 4, 2024 | K-0271 | Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 31, 2024 |
| Apr 4, 2024 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 31, 2024 |
| Apr 4, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 31, 2024 |
| Apr 4, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 20, 2024 |
| Apr 4, 2024 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 1, 2024 |
| Apr 4, 2024 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 3, 2024 |
| Apr 4, 2024 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 26, 2024 |
| Apr 4, 2024 | K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Apr 20, 2024 |
| Apr 4, 2024 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Apr 20, 2024 |
| Apr 4, 2024 | F-0625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Resident Rights Deficiencies · Resident rights & abuse/neglect | C · Minimal Widespread | Corrected Apr 26, 2024 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 5.44 (case-mix index 1.09).
| OPERATIONAL/MANAGERIAL CONTROL |
| not provided |
| Aug 1, 2020 |
| Dennis Spano | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 1, 2025 |
| Daniel Coenen | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2024 |
| Cindy Denk | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Oct 1, 2012 |
| Emily Durand | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2023 |
| Michael Ebersold | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jul 1, 2016 |
| Paul Fisch | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Sep 1, 2020 |
| Lloyd Haas | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Sep 1, 2020 |
| Paul Mclellan | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2026 |
| Richard Vaplon | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2026 |
| Beverly Youngbauer | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2023 |
| Kristi Petersen | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jan 1, 2025 |
| James Root | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Sep 1, 2020 |
| John Wolfe | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jan 1, 1992 |
| Kristi Petersen | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 3, 2025 |
| Dennis Spano | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 3, 2025 |