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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D24 | E15 | F7 |
| Minimal | A· | B· | C1 |
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 | |
|---|---|---|---|---|---|---|
| Apr 1, 2026 | Fire safety | Fire Safety Standard | 7 | Potential harm | — | Open → |
| Apr 1, 2026 | Health | Health Standard | 5 | Potential harm | — | Open → |
| Apr 21, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 18, 2024 | Fire safety | Fire Safety Standard | 7 | Potential harm | — | Open → |
| Dec 18, 2024 | Health | Health Standard | 10 | Potential harm | — | Open → |
| Jul 29, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jan 11, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Nov 9, 2023 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Sep 13, 2023 | Fire safety | Fire Safety Standard | 7 | Potential harm | — | Open → |
| Sep 13, 2023 | Health | Health Standard | 5 | Potential harm | — | Open → |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D24 | E15 | F7 |
| Minimal | A· | B· | C1 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Apr 1, 2026 | 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 Apr 20, 2026 | |
| Apr 1, 2026 | K-0271 | Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 1, 2026 | |
| Apr 1, 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.
2 facilities in 2 states. CMS chain ID 486.
Chain average overall rating (CMS): 3
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Sue Anderson | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Feb 28, 2022 |
| Paige Bass | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 1, 2025 |
| Daniel Beardmore | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Nov 12, 2024 |
| Judith Bell | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 1, 2023 |
| Mary Brown | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 4, 2018 |
| Janice Burnett | Individual |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Harbor Haven Health & Rehabilitation 459 E 1st Street, Fond Du Lac, WI 54935 CCN 525534 | 0.5 km | 85 | Jun 30, 2026 | 21 | — | |
| Avina on Division 517 E Division St, Fond Du Lac, WI 54935 CCN 525522 | 0.6 km | 50 | Aug 5, 2026 | 591 IJ2 harm | $58k | |
| Avina of Fond Du Lac 115 E Arndt St, Fond Du Lac, WI 54935 CCN 525270 | 1.1 km | 50 | Jul 6, 2026 | 651 IJ | $7,446 | |
| Edenbrook of Fond Du Lac 265 S National Ave, Fond Du Lac, WI 54935 CCN 525274 | 1.3 km | 90 | Jun 11, 2025 | 361 IJ | $9,113 | |
| Fond Du Lac Lutheran Home 244 N Macy St, Fond Du Lac, WI 54935 CCN 525655 | 1.4 km | 85 | May 14, 2026 | 881 IJ1 harm1 open | $9,113 |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 525595 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 525595 | 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
| Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety |
| D · Potential harm Isolated |
| Corrected Apr 20, 2026 |
| Apr 1, 2026 | K-0753 | Have restrictions on the use of highly flammable decorations. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 20, 2026 |
| Apr 1, 2026 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 30, 2026 |
| Apr 1, 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 20, 2026 |
| Apr 1, 2026 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 24, 2026 |
| Apr 1, 2026 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 10, 2026 |
| Apr 1, 2026 | 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 Apr 10, 2026 |
| Apr 1, 2026 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Apr 10, 2026 |
| Apr 1, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 10, 2026 |
| Apr 1, 2026 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Apr 20, 2026 |
| Apr 21, 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 May 16, 2025 | Complaint |
| Dec 18, 2024 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 31, 2025 |
| Dec 18, 2024 | 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 Jan 31, 2025 |
| Dec 18, 2024 | K-0281 | Install proper backup exit lighting. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 3, 2025 |
| Dec 18, 2024 | K-0311 | Have an enclosure around a vertical opening shaft. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 18, 2025 |
| Dec 18, 2024 | K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 18, 2025 |
| Dec 18, 2024 | K-0912 | Have power receptacles that are properly grounded. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 18, 2025 |
| Dec 18, 2024 | 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 Jan 31, 2025 |
| Dec 18, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jan 31, 2025 |
| Dec 18, 2024 | 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 Jan 31, 2025 |
| Dec 18, 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 Jan 31, 2025 |
| Dec 18, 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 | D · Potential harm Isolated | Corrected Jan 31, 2025 |
| Dec 18, 2024 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 18, 2025 |
| Dec 18, 2024 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 31, 2025 |
| Dec 18, 2024 | 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 Jan 31, 2025 |
| Dec 18, 2024 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 31, 2025 |
| Dec 18, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 31, 2025 |
| Dec 18, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Jan 31, 2025 |
| Jul 29, 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 29, 2024 | Complaint |
| Jul 29, 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 | D · Potential harm Isolated | Corrected Aug 29, 2024 | Complaint |
| Jan 11, 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 | E · Potential harm Pattern | Corrected Feb 11, 2024 | Complaint |
| Nov 9, 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 | D · Potential harm Isolated | Corrected Dec 9, 2023 | Complaint |
| Nov 9, 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 Dec 9, 2023 | Complaint |
| Sep 13, 2023 | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Sep 28, 2023 |
| Sep 13, 2023 | K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Waiver granted Feb 27, 2024 |
| Sep 13, 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 Oct 20, 2023 |
| Sep 13, 2023 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 15, 2023 |
| Sep 13, 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. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 15, 2023 |
| Sep 13, 2023 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 15, 2023 |
| Sep 13, 2023 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 8, 2023 |
| Sep 13, 2023 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 13, 2023 |
| Sep 13, 2023 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 13, 2023 |
| Sep 13, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Oct 13, 2023 |
| Sep 13, 2023 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Oct 13, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.10 (case-mix index 1.21).
| Operational / managerial control |
| MANAGING CONTROL - GOVERNING BODY |
| not provided |
| Jan 1, 2022 |
| Rick Corcoran | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Oct 1, 2017 |
| Marie Devlin | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jun 1, 2018 |
| Peter Dolan | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 1, 2024 |
| Rhea Emmer | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Feb 28, 2022 |
| Denise Gloede | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Nov 1, 2024 |
| John Hardt | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 1, 2022 |
| David Hartenbach | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 1, 2025 |
| Peng Her | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Dec 13, 2023 |
| Mark Holzman | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Dec 13, 2023 |
| Donald Imholz | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jun 1, 2018 |
| Laura Kaiser | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | May 1, 2017 |
| Joan Karsten | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | May 11, 2021 |
| Carolyn Kindle | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 1, 2022 |
| Patti Leitzen Fye | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 1, 2024 |
| Jennifer Maskel | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 1, 2019 |
| Wayne Matzke | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | May 11, 2021 |
| Thomas Nairn | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 1, 2024 |
| Olivia Otte | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Nov 12, 2024 |
| Mary Pandl | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 1, 2024 |
| Matthew Pogodzinski | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Nov 29, 2022 |
| Victor Radina | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jun 1, 2025 |
| Samuel Ross | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Sep 16, 2020 |
| Kevin Smith | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 1, 2024 |
| Wesley Sparkman | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Dec 1, 2015 |
| Joseph Valdez | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Aug 1, 2022 |
| Tomas Valdivia | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 1, 2023 |
| James Walkup | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 1, 2025 |
| James Whalen | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Oct 1, 2017 |
| Amy Wilson | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jun 1, 2025 |
| Agnesian Healthcare Inc | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jun 1, 1978 |
| Ssm Health Care Corporation | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 1, 2018 |
| Ssm Health Care of Wisconsin Inc | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 1, 2018 |
| Sue Anderson | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 1, 2024 |
| Denise Gloede | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 1, 2024 |
| Kari Krueger | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 1, 2022 |
| Jennifer Mabry | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 1, 2025 |
| Victor Radina | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jun 1, 2025 |
| Lisa Weber | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Nov 1, 2024 |
| Amy Wilson | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jun 1, 2025 |
| Kevin Smith | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2024 |
| James Walkup | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2025 |
| Denise Gloede | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Nov 1, 2024 |
| Kari Krueger | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jun 26, 2025 |
| Victor Radina | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jun 1, 2025 |
| Kevin Smith | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jan 1, 2024 |
| James Walkup | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jan 1, 2025 |
| Amy Wilson | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jun 1, 2025 |
| Ssm Health Care Corporation | Organization | Additional disclosable party | ADP OF THE SNF | not provided | May 22, 2025 |
| Ssm Health Care of Wisconsin Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | May 21, 2025 |
| Jennifer Mabry | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 31, 2026 |
| Lisa Weber | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 16, 2025 |