Cycle 1
Health 2025-04-23 · Fire 2025-04-23
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fond Du Lac, WI
Harbor Haven Health & Rehabilitation
5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
459 E 1st Street, Fond Du Lac, WI
(920) 929-3500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
75
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.12
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.25
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.11
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.48
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.13
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.79
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.23
CMS adjusted RN staffing hours
Adjusted total hours
4.94
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,308
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9981
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.65
Baseline 19.91% · Performance 20.20% · Measure score 2.65 · Achievement 2.65 · Improvement 0
Healthcare-associated infections
2.12
Baseline 5.72% · Performance 7.20% · Measure score 2.12 · Achievement 2.12 · Improvement 0
Total nurse turnover
6.60
Baseline 42.59% · Performance 36.70% · Measure score 6.60 · Achievement 6.60 · Improvement 2.82
Adjusted total nurse staffing
6.61
Baseline 4.14 hours · Performance 4.96 hours · Measure score 6.61 · Achievement 6.61 · Improvement 4.49
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.15% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 192 · Observed rate 7.81% · Lower 95% interval 7.51% |
| Discharge to community | 70.47% |
50.57%
19.9 pts better
|
Better than the National Rate · Eligible stays 187 · Observed rate 72.19% · Lower 95% interval 64.65% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.29% |
95.27%
3 pts better
|
Numerator 115 · Denominator 117 |
| Falls with major injury | 1.71% |
0.77%
0.9 pts worse
|
Numerator 2 · Denominator 117 |
| Discharge self-care score | 59.57% |
53.69%
5.9 pts better
|
Numerator 56 · Denominator 94 |
| Discharge mobility score | 51.06% |
50.94%
0.1 pts better
|
Numerator 48 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 117 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 102 · Observed rate 5.88% · Lower 95% interval 4.08% |
| Staff COVID-19 vaccination coverage | 69.84% |
8.2%
61.6 pts better
|
Numerator 132 · Denominator 189 |
| Staff flu vaccination coverage | 91.51% |
42%
49.5 pts better
|
Numerator 248 · Denominator 271 |
| Discharge function score | 62.77% |
56.45%
6.3 pts better
|
Numerator 59 · Denominator 94 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 72 · Denominator 72 |
| Resident COVID-19 vaccinations up to date | 37.68% |
25.2%
12.5 pts better
|
Numerator 26 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.8 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.2
0.3 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.5 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.1% |
95.0%
5.9 pts worse
|
95.5%
6.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.1% · Q3 2.0% · Q4 1.9% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
5.0%
0.2 pts worse
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.2% · Q3 2.0% · Q4 6.1% · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
4.9%
2.4 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.3% · Q3 2.6% · Q4 0.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
16.6%
4.1 pts better
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 9.1% · Q3 16.3% · Q4 14.9% · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.3% |
16.7%
12.6 pts worse
|
16.7%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 28.9% · Q3 27.3% · Q4 26.8% · 4Q avg 29.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.9% |
21.1%
7.2 pts better
|
16.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 9.0% · Q4 3.6% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.0% |
17.3%
4.7 pts worse
|
14.9%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 22.0% · Q3 25.0% · Q4 9.1% · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
3.0%
1.4 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.9% · Q3 2.2% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.3% |
25.5%
5.2 pts better
|
19.8%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 17.3% · Q3 17.0% · Q4 23.4% · 4Q avg 20.3% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
5.5%
1.3 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.7% · Q3 4.1% · Q4 5.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.8%
13.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.4% |
15.0%
0.6 pts better
|
12.0%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.4% · Observed 12.9% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.3%
1 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.6% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
82.2%
14.7 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
22.7%
4.2 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 15.5% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-21 · Fire 2024-02-21
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-12-21 · Fire 2022-12-21
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-23
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-04-23
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-04-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-04-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-23
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-23
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-20
F · Potential for more than minimal harm
2024-02-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-21
E · Potential for more than minimal harm
2024-02-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-21
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-03-18
F · Potential for more than minimal harm
2022-12-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-12-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-13
E · Potential for more than minimal harm
2022-12-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-17
E · Potential for more than minimal harm
2022-12-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-12-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-01-02
D · Potential for more than minimal harm
2022-12-21
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-01-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-02-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-03-21
E · Potential for more than minimal harm
2023-03-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-01
Penalties and ownership
What sits behind the stars
Ownership
Fond Du Lac County
Operational/Managerial Control · Organization
Moon, Jessica
W-2 Managing Employee · Individual
Radmer, Mark
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Avina on Division
Fond Du Lac, WI
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
St Francis Home
Fond Du Lac, WI
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Edenbrook Of Fond Du Lac
Fond Du Lac, WI
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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