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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J3 | K· | L· |
| Actual harm | G5 | H· | I· |
| Potential harm | D41 | E17 | F12 |
| Minimal | A· | B2 | C2 |
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 | |
|---|---|---|---|---|---|---|
| Mar 26, 2026 | Fire safety | Fire Safety Standard | 3 | Potential harm | — | Open → |
| Mar 26, 2026 | Health | Health Standard | 9 | Actual harm | — | Open → |
| Jan 7, 2026 | Health | Health Complaint | 2 | Actual harm | — | Open → |
| Jun 13, 2025 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Mar 5, 2025 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Nov 14, 2024 | Fire safety | Fire Safety Standard | 6 | Potential harm | — | Open → |
| Nov 14, 2024 | Health | Health Complaint, Health Standard | 20 | Actual harm | — | Open → |
| Aug 7, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Aug 17, 2023 | Fire safety | Fire Safety Standard | 6 | Potential harm | — | Open → |
| Aug 17, 2023 | Health | Health Standard | 30 | Immediate jeopardy | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Mar 26, 2026 | Denial of payment for new admissions | — | Apr 22, 2026 · 21 days | 525524|Payment Denial|2026-04-22 |
| Mar 26, 2026 | Civil money penalty (fine) | $119,850 | — | 525524|Fine|141599 |
| Jan 7, 2026 | Denial of payment for new admissions | — | Feb 7, 2026 · 23 days | 525524|Payment Denial|2026-02-07 |
| Jan 7, 2026 | Civil money penalty (fine) | $19,115 | — | 525524|Fine|141589 |
| Nov 14, 2024 | Denial of payment for new admissions | — | Dec 24, 2024 · 112 days | 525524|Payment Denial|2024-12-24 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J3 | K· | L· |
| Actual harm | G5 | H· | I· |
| Potential harm | D41 | E17 | F12 |
| Minimal | A· | B2 | C2 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Mar 26, 2026 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected May 13, 2026 | |
| Mar 26, 2026 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 13, 2026 | |
| Mar 26, 2026 | K-0353 |
“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.
5 facilities in 1 states. CMS chain ID 874.
Chain average overall rating (CMS): 2
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Marquardt Village Inc | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Jan 4, 2022 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Marquardt Village Inc | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Jan 4, 2022 |
| Illuminus Inc | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 4, 2022 |
| Marquardt Village Inc | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 4, 2022 |
| Tesla Lipke | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Marquardt Memorial Manor 1020 Hill St., Watertown, WI 53098 CCN 525543 | 140 | Jul 1, 2026 | 713 harm | $27k | |
| St Elizabeth Nursing Home 109 S. Atwood Ave., Janesville, WI 53545 CCN 525639 | 43 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Luther Manor 4545 N 92nd St, Milwaukee, WI 53225 CCN 525588 | 1.9 km | 99 | Jul 29, 2026 | 853 IJ4 harm1 open | $164k | |
| Lutheran Home 7500 W North Ave, Wauwatosa, WI 53213 CCN 525545 | 3.2 km | 160 | Jun 10, 2025 | 311 harm | — | |
| Congregational Home, Inc. 13900 W Burleigh Rd, Brookfield, WI 53005 CCN 525700 | 4.8 km | 66 | Jul 31, 2025 | 331 harm | — | |
| St Camillus Health Center 10101 W Wisconsin Ave, Wauwatosa, WI 53226 CCN 525382 | 5.3 km | 50 | Jul 23, 2026 | 362 IJ | $66k | |
| Milwaukee Health and Rehab 3216 W Highland Blvd, Milwaukee, WI 53208 CCN 525417 | 7.5 km | 95 | Dec 8, 2025 | 60 | — | |
| Resolve at West Allis Respiratory and Rehab 9047 W Greenfield Ave, West Allis, WI 53214 CCN 525108 | 7.6 km | 152 | Aug 4, 2026 | 811 IJ4 harm | $130k | |
| Bayshore Nursing & Rehab 1300 West Silver Spring Dr, Glendale, WI 53209 CCN 525371SFF CandidateAbuse icon | 9.1 km | 112 | Apr 30, 2026 | 1797 IJ3 harm1 open | $424k | |
| Bradley Estates Nursing and Rehab LLC 6735 W Bradley Rd, Milwaukee, WI 53223 CCN 525325SFF CandidateAbuse icon | 9.1 km | 198 | Jul 9, 2026 | 1903 IJ11 harm | $305k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 525524 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 525524 | 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
| Nov 14, 2024 | Civil money penalty (fine) | $204,523 | — | 525524|Fine|61253 |
| Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety |
| E · Potential harm Pattern |
| Corrected Apr 13, 2026 |
| Mar 26, 2026 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 17, 2026 |
| Mar 26, 2026 | F-0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 13, 2026 |
| Mar 26, 2026 | 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 | D · Potential harm Isolated | Corrected Apr 20, 2026 |
| Mar 26, 2026 | F-0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 20, 2026 |
| Mar 26, 2026 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 20, 2026 |
| Mar 26, 2026 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 20, 2026 |
| Mar 26, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Apr 20, 2026 |
| Mar 26, 2026 | F-0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Apr 20, 2026 |
| Mar 26, 2026 | F-0887 | 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. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 20, 2026 |
| Jan 7, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Mar 2, 2026 | Complaint |
| Jan 7, 2026 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Feb 2, 2026 | Complaint |
| Jun 13, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 11, 2025 | Complaint |
| Jun 13, 2025 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jul 11, 2025 | Complaint |
| Jun 13, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jul 11, 2025 | Complaint |
| Mar 5, 2025 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | G · Actual harm Isolated | Corrected Apr 15, 2025 | Complaint |
| Nov 14, 2024 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Apr 15, 2025 | Complaint |
| Nov 14, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Apr 15, 2025 |
| Nov 14, 2024 | E-0018 | Establish procedures for tracking staff and patients during an emergency. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Dec 19, 2024 |
| Nov 14, 2024 | E-0035 | Provide family notifications of emergency plan. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Dec 19, 2024 |
| Nov 14, 2024 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Dec 19, 2024 |
| Nov 14, 2024 | K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 19, 2024 |
| Nov 14, 2024 | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 19, 2024 |
| Nov 14, 2024 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 19, 2024 |
| Nov 14, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 19, 2024 |
| Nov 14, 2024 | F-0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 19, 2024 |
| Nov 14, 2024 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 19, 2024 |
| Nov 14, 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 | E · Potential harm Pattern | Corrected Dec 19, 2024 |
| Nov 14, 2024 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 19, 2024 |
| Nov 14, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 15, 2025 |
| Nov 14, 2024 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 19, 2024 | Complaint |
| Nov 14, 2024 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 19, 2024 |
| Nov 14, 2024 | 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 | D · Potential harm Isolated | Corrected Dec 19, 2024 |
| Nov 14, 2024 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Dec 19, 2024 | Complaint |
| Nov 14, 2024 | F-0745 | Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 19, 2024 |
| Nov 14, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Dec 19, 2024 |
| Nov 14, 2024 | F-0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Dec 19, 2024 |
| Nov 14, 2024 | F-0838 | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Dec 19, 2024 |
| Nov 14, 2024 | F-0849 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Dec 19, 2024 |
| Nov 14, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Apr 15, 2025 |
| Nov 14, 2024 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Dec 19, 2024 |
| Nov 14, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Dec 19, 2024 |
| Aug 7, 2024 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 24, 2024 | Complaint |
| Aug 7, 2024 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 24, 2024 | Complaint |
| Aug 17, 2023 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | J · Immediate jeopardy Isolated | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | J · Immediate jeopardy Isolated | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected Sep 13, 2023 |
| Aug 17, 2023 | K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 25, 2023 |
| Aug 17, 2023 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 25, 2023 |
| Aug 17, 2023 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 21, 2023 |
| Aug 17, 2023 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 25, 2023 |
| Aug 17, 2023 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 21, 2023 |
| Aug 17, 2023 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0687 | Provide appropriate foot care. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 13, 2023 |
| Aug 17, 2023 | 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 | D · Potential harm Isolated | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0745 | Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0773 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Sep 13, 2023 |
| Aug 17, 2023 | 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 | D · Potential harm Isolated | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0941 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Sep 13, 2023 |
| Aug 17, 2023 | F-0949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Sep 13, 2023 |
| Aug 17, 2023 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Aug 22, 2023 |
| Aug 17, 2023 | 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 | B · Minimal Pattern | Corrected Sep 13, 2023 |
| Aug 17, 2023 | 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 | B · Minimal Pattern | Corrected Sep 13, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.92 (case-mix index 1.30).
| Apr 16, 2025 |
| Julie Marks | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jun 9, 2025 |
| Matthew Mauthe | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 4, 2022 |
| Sarfraz Sidhu | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 2, 2021 |
| Scott Dettman | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 4, 2022 |
| Todd Fischer | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 4, 2022 |
| Steven Heroux | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Aug 1, 2024 |
| Kevin Kohlhoff | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Sep 1, 2023 |
| Dennis Konkol | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Oct 1, 2024 |
| Robert Meidenbauer | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 4, 2022 |
| Katie Van Der Linden | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 4, 2022 |
| Lynne Wagner | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Oct 1, 2024 |
| Julie Marks | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jun 9, 2025 |
| Matthew Mauthe | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jan 4, 2022 |
| Illuminus Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 24, 2025 |
| Tesla Lipke | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 24, 2025 |
| Julie Marks | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jun 9, 2025 |
| Matthew Mauthe | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jan 4, 2022 |
| Sarfraz Sidhu | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jul 2, 2021 |
| Apr 28, 2026 |
871 IJ1 harm |
| $31k |
| Fond Du Lac Lutheran Home 244 N Macy St, Fond Du Lac, WI 54935 CCN 525655 | 85 | May 14, 2026 | 881 IJ1 harm1 open | $9,113 |
| St Dominic Villa 2375 Sinsinawa Rd, Hazel Green, WI 53811 CCN 525660 | 62 | Dec 22, 2025 | 514 IJ2 harm | $50k |