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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D45 | E25 | F13 |
| Minimal | A· | B· | 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 | |
|---|---|---|---|---|---|---|
| Apr 28, 2026 | Fire safety | Fire Safety Standard | 10 | Potential harm | — | Open → |
| Apr 28, 2026 | Health | Health Complaint, Health Standard | 8 | Potential harm | — | Open → |
| Feb 3, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 13, 2025 | Fire safety | Fire Safety Standard | 12 | Potential harm | — | Open → |
| Feb 13, 2025 | Health | Health Standard | 8 | Potential harm | — | Open → |
| Jan 8, 2025 | Health | Health Complaint | 4 | Actual harm | — | Open → |
| Oct 17, 2024 | Health | Health Complaint | 8 | Immediate jeopardy | — | Open → |
| Jul 17, 2024 | Health | Health Complaint | 7 | Potential harm | — | Open → |
| Jun 21, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Jan 30, 2024 | Fire safety | Fire Safety Standard | 10 | Potential harm | — | Open → |
| Jan 30, 2024 | Health | Health Complaint, Health Standard | 15 | Potential harm | — | Open → |
| Nov 9, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Jan 8, 2025 | Civil money penalty (fine) | $8,824 | — | 525639|Fine|61271 |
| Oct 17, 2024 | Civil money penalty (fine) | $22,347 | — | 525639|Fine|61235 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D45 | E25 | F13 |
| Minimal | A· | B· | C2 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Apr 28, 2026 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 14, 2026 | |
| Apr 28, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 19, 2026 | |
| Apr 28, 2026 | K-0363 |
“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 |
|---|---|---|---|---|---|
| Illuminus Inc | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 30, 2018 |
| Matthew Mauthe | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 30, 2018 |
| Sarfraz Sidhu | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 6, 2021 |
| Deanna Wilson | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Oct 28, 2024 |
| Scott Dettman | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Sep 1, 2020 |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| St. Anne's Salvatorian Campus 3800 N 92nd St, Milwaukee, WI 53222 CCN 525524 | 50 | Mar 26, 2026 | 823 IJ5 harm | $343k | |
| Marquardt Memorial Manor 1020 Hill St., Watertown, WI 53098 CCN 525543 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Mercy Manor Transition Center 1000 Mineral Point Ave., Janesville, WI 53547 CCN 525666 | 1.4 km | 28 | Jul 17, 2025 | 191 IJ | $54k | |
| Rock Haven 3400 N. Cty Trk Hwy F, Janesville, WI 53547 CCN 525390 | 2.6 km | 128 | Jan 29, 2026 | 351 IJ | $43k | |
| Oak Park Place of Janesville 700 Myrtle Way, Janesville, WI 53545 CCN 525728 | 2.7 km | 35 | Jul 29, 2026 | 654 harm | — | |
| Cedar Crest Health Center 1702 S. River Rd., Janesville, WI 53546 CCN 525649 | 4.4 km | 71 | Apr 2, 2026 | 20 | — | |
| Beloit Health and Rehabilitation Center 1905 W Hart Rd, Beloit, WI 53511 CCN 525273 | 15.2 km | 110 | Jul 8, 2026 | 814 harm1 open | $47k | |
| Autumn Lake Healthcare at Beloit 2121 Pioneer Dr., Beloit, WI 53511 CCN 525663 | 17 km | 120 | Jul 24, 2026 | 441 IJ2 harm | — | |
| Alden Meadow Park Hcc 709 Meadow Park Dr., Clinton, WI 53525 CCN 525508 | 18.1 km | 94 | Apr 23, 2026 | 401 harm | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 525639 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 525639 | 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
| Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety |
| E · Potential harm Pattern |
| Corrected May 14, 2026 |
| Apr 28, 2026 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 16, 2026 |
| Apr 28, 2026 | 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 May 15, 2026 |
| Apr 28, 2026 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 13, 2026 |
| Apr 28, 2026 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 5, 2026 |
| Apr 28, 2026 | K-0753 | Have restrictions on the use of highly flammable decorations. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 13, 2026 |
| Apr 28, 2026 | 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 May 14, 2026 |
| Apr 28, 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 May 13, 2026 |
| Apr 28, 2026 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 22, 2026 |
| Apr 28, 2026 | 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 | D · Potential harm Isolated | Corrected May 22, 2026 | Complaint |
| Apr 28, 2026 | 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 May 22, 2026 |
| Apr 28, 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 May 22, 2026 |
| Apr 28, 2026 | 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 May 22, 2026 |
| Apr 28, 2026 | 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 May 22, 2026 | Complaint |
| Apr 28, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected May 22, 2026 |
| Apr 28, 2026 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected May 22, 2026 |
| Feb 3, 2026 | 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 | E · Potential harm Pattern | Corrected Feb 24, 2026 | Complaint |
| Feb 13, 2025 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Feb 13, 2025 | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 10, 2025 |
| Feb 13, 2025 | K-0331 | Construct fire resistant interior walls. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 14, 2025 |
| Feb 13, 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 Mar 4, 2025 |
| Feb 13, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 13, 2025 |
| Feb 13, 2025 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 10, 2025 |
| Feb 13, 2025 | K-0912 | Have power receptacles that are properly grounded. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 26, 2025 |
| Feb 13, 2025 | 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 Mar 18, 2025 |
| Feb 13, 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 Mar 14, 2025 |
| Feb 13, 2025 | K-0919 | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Feb 26, 2025 |
| Feb 13, 2025 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 26, 2025 |
| Feb 13, 2025 | 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 Mar 14, 2025 |
| Feb 13, 2025 | 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 | D · Potential harm Isolated | Corrected Mar 14, 2025 |
| Feb 13, 2025 | 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 Mar 14, 2025 |
| Feb 13, 2025 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 14, 2025 |
| Feb 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 Mar 14, 2025 |
| Feb 13, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Feb 13, 2025 | 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 Mar 14, 2025 |
| Feb 13, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Feb 28, 2025 |
| Jan 8, 2025 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | G · Actual harm Isolated | Corrected Jan 22, 2025 | Complaint |
| Jan 8, 2025 | 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 22, 2025 | Complaint |
| Jan 8, 2025 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 22, 2025 | Complaint |
| Jan 8, 2025 | 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 Jan 22, 2025 | Complaint |
| Oct 17, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected Nov 15, 2024 | Complaint |
| Oct 17, 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 Nov 15, 2024 | Complaint |
| Oct 17, 2024 | F-0687 | Provide appropriate foot care. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 15, 2024 | Complaint |
| Oct 17, 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 Nov 15, 2024 | Complaint |
| Oct 17, 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 | F · Potential harm Widespread | Corrected Nov 15, 2024 | Complaint |
| Oct 17, 2024 | F-0758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 15, 2024 | Complaint |
| Oct 17, 2024 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 15, 2024 | Complaint |
| Oct 17, 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 Nov 15, 2024 | Complaint |
| Jul 17, 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 Aug 16, 2024 | Complaint |
| Jul 17, 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 16, 2024 | Complaint |
| Jul 17, 2024 | 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 | E · Potential harm Pattern | Corrected Aug 16, 2024 | Complaint |
| Jul 17, 2024 | F-0660 | Plan the resident's discharge to meet the resident's goals and needs. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 16, 2024 | Complaint |
| Jul 17, 2024 | 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 | D · Potential harm Isolated | Corrected Aug 16, 2024 | Complaint |
| Jul 17, 2024 | 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 Aug 16, 2024 | Complaint |
| Jul 17, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Aug 16, 2024 | Complaint |
| Jun 21, 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 Jul 18, 2024 | Complaint |
| Jun 21, 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 Jul 18, 2024 | Complaint |
| Jun 21, 2024 | F-0624 | Prepare residents for a safe transfer or discharge from the nursing home. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 18, 2024 | Complaint |
| Jan 30, 2024 | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 1, 2024 |
| Jan 30, 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 | D · Potential harm Isolated | Corrected Mar 3, 2024 |
| Jan 30, 2024 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 1, 2024 |
| Jan 30, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 4, 2024 |
| Jan 30, 2024 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 1, 2024 |
| Jan 30, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 1, 2024 |
| Jan 30, 2024 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Waiver granted May 29, 2024 |
| Jan 30, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Waiver granted May 10, 2024 |
| Jan 30, 2024 | K-0753 | Have restrictions on the use of highly flammable decorations. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 1, 2024 |
| Jan 30, 2024 | K-0912 | Have power receptacles that are properly grounded. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 8, 2024 |
| Jan 30, 2024 | F-0576 | Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 1, 2024 | Complaint |
| Jan 30, 2024 | 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 | E · Potential harm Pattern | Corrected Mar 1, 2024 | Complaint |
| Jan 30, 2024 | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 1, 2024 | Complaint |
| Jan 30, 2024 | 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 | D · Potential harm Isolated | Corrected Feb 23, 2024 |
| Jan 30, 2024 | F-0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jan 31, 2024 | Complaint |
| Jan 30, 2024 | 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 Mar 1, 2024 | Complaint |
| Jan 30, 2024 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 1, 2024 | Complaint |
| Jan 30, 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 Mar 1, 2024 | Complaint |
| Jan 30, 2024 | F-0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 1, 2024 | Complaint |
| Jan 30, 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 Mar 1, 2024 | Complaint |
| Jan 30, 2024 | F-0758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 1, 2024 | Complaint |
| Jan 30, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Mar 1, 2024 | Complaint |
| Jan 30, 2024 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 1, 2024 | Complaint |
| Jan 30, 2024 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 1, 2024 | Complaint |
| Jan 30, 2024 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records | C · Minimal Widespread | Corrected Mar 1, 2024 |
| Nov 9, 2023 | 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 Dec 11, 2023 | Complaint |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.56 (case-mix index 1.21).
| Todd Fischer | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Apr 30, 2018 |
| 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 | Sep 1, 2019 |
| Katie Van Der Linden | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | May 1, 2021 |
| 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 | Apr 30, 2018 |
| Illuminus Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Oct 17, 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 | Apr 30, 2018 |
| Sarfraz Sidhu | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 6, 2021 |
| Deanna Wilson | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 22, 2025 |
| 140 |
| Jul 1, 2026 |
713 harm |
| $27k |
| 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 |