Aspirus Divine Savior Hospital
An acute care hospital in Portage, Wisconsin 53901
2817 New Pinery Road, Portage, Wisconsin 53901. (608) 742-4131.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 3of 5 CMS’s overall rating
- 3of 5 patient survey rating
- 3 deficiencies cited in the last three years
- 73 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Jan 26, 2024: a complaint inspection.
3 deficiencies cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
3 deficiencies in 2 months of the last 36. Last cited Jan 2024. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Jan 26, 2024: complaint inspection1 deficiency
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Initial Comments - Not A Deficiency Citation
The inspectors’ words, 216 words
“An unannounced, federally authorized onsite Complaint survey was conducted on 01/26/2024 at Aspirus Divine Savior 2817 New Pinery Road Portage WI in response to complaint #WI00053403. The Aspirus Divine Savior Hospital was found to be in compliance with the requirements of the following applicable regulations for participation in Medicare: 42 CFR Subpart 482.41- Condition of Participation: Physical Environment was MET 42 CFR Subpart 482.41(b)- Standard: Life Safety from Fire was MET NFPA 101 (2012 ed.) - Life Safety Code was MET (Chapter 19-Existing Health Care) The Divine Savior is a three-story structure built in 2003, with Type II (1,1,1) construction. The campus also has a medical office building (MOB) that is attached to the health care occupancy and was surveyed as a business occupancy, since the provider number is used, and the MOB was separated with 2-hour rated construction. All portions of the facility were sprinkled. The facility had an emergency generator that provided power to the emergency loads. The facility contained 4 patient care wings and 14 smoke compartments. Divine Savior is licensed for 73 beds, with a census of 35 patients at the time of the survey. The facility was surveyed under the 2012 Life Safety Code, Chapter 19, for an existing healthcare occupancy. No federal deficiency of the Life Safety Code was cited.”
Dec 6, 2023: complaint inspection2 deficiencies
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Initial Comments - Not A Deficiency Citation
The inspectors’ words, 235 words
“An unannounced, federally authorized onsite Complaint survey was conducted on 12/06/2022 at Aspirus Divine Savior Hospital located at 2817 New Pinery Rd, Portage, WI 53901. The life safety code surveyor completed the following tasks on 12/06/2023 in response to complaint #WI00052546. The Aspirus Divine Savior Hospital was found to not be in compliance with requirements of the following applicable regulations for participation in Medicare: 42 CFR Subpart 482.41- Condition of Participation: Physical Environment was NOT MET 42 CFR Subpart 482.41(b)- Standard: Life Safety from Fire was NOT MET NFPA 101 (2012 ed.) - Life Safety Code was NOT MET (Chapter 19-Existing Health Care) The Divine Savior is a three-story structure built in 2003, with Type II (1,1,1) construction. The campus also has a medical office building (MOB) that is attached to the health care occupancy, and was surveyed as a business occupancy, since the provider number is used and the MOB was separated with 2-hour rated construction. All portions of the facility were sprinkled. The facility had an emergency generator that provided power to the emergency loads. The facility contained 4 patient care wings and 14 smoke compartments. Divine Savior is licensed for 73 beds, with a census of 35 patients at the time of the survey. The facility was surveyed under the 2012 Life Safety Code, Chapter 19, for an existing healthcare occupancy. One (1) federal deficiency of the Life Safety Code was cited.”
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Corridors - Construction Of Walls
The inspectors’ words, 316 words
“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 42046 Based on observation and interview, the facility did not provide 1-hour fire rated corridor wall separations as required in NFPA 101, 2012 edition, Sections 19.3.6.2.1, 8.4.2, 8.2.3, 8.2.3.1, 8.2.3.1.1, 8.3.5 and 8.3.5.1. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Findings include: On 12/06/2023 at 12:16 PM, observation in the corridor on the east side of the lab between the lab and the boiler room revealed a corridor wall that was not constructed to a 1-hour fire rating as indicated by the “1-HR FIRE” stenciling on the wall. There were 2: one foot X one foot scab drywall patches on either side of an I beam which penetrated the wall on an angle and 2: two-foot X one-foot purple faced drywall scab patches. Scab patches do not provide protection in accordance with the listed penetration firestop assembly Gypsum Association GA-225-2019. This deficient practice was confirmed by Staff A and B at the time of discovery.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jan 26, 2024 | Complaint inspection | 1 deficiency cited |
| Dec 6, 2023 | Complaint inspection | 2 deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 3 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 5; safety of care, 0 better and 0 worse of 2; readmission, 0 better and 1 worse of 6.
- Patients rate it 3 of 5 in CMS’s patient survey (169 surveys completed, Oct 1, 2024 to Sep 30, 2025): 63% rated it 9 or 10 out of 10, and 58% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): C. diff infections, no different than national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart failure 15.3%, pneumonia 13.6%, COPD 8.8%, stroke 11.9%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart failure 22.8%, pneumonia 17.3%, COPD 19.8%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 153 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 1% left before being seen.
- 89% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.81 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 3 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 3 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: voluntary non-profit - private.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 3 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
- 67% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Aspirus, Inc. owns 100% directly since Jan 31, 2020.
- Aspirus, Inc. runs it.
- 25 owners or officers are people: Jennifer Redman-Schell (corporate director); Michael Holzhueter (managing employee (on the payroll)); Jerry M Yang (corporate director); Jerry M Yang (managing employee (on the payroll)); Jerry M Yang (runs it (operational or managerial control)); Justin Huebner (corporate director); Joshua Pogorelec (corporate director, 0%); Michael Bovee (corporate director); Susan Kreckman (corporate director, 0%); Lynn Vogt (corporate director, 0%); Trina Daniels (corporate director); Mary Ironside (corporate director); Daniel Burns (corporate director); Craig Broeren (corporate director); Lori Peck (corporate director); Lori Peck (managing employee (on the payroll)); Lori Peck (runs it (operational or managerial control)); Tyler Hack (corporate director); Tyler Hack (managing employee (on the payroll)); Tyler Hack (runs it (operational or managerial control)); Bonita Kolrud (corporate director); Matthew F Heywood (corporate officer, 0%); Matthew F Heywood (managing employee (on the payroll)); Matthew F Heywood (runs it (operational or managerial control)); Rebecca Sommer (corporate director).
- CMS’s Provider of Services file records 2 changes of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Aspirus, Inc. | Owns 5% or more directly | 100% | Jan 31, 2020 |
| Aspirus, Inc. | Runs it (operational or managerial control) | 100% | Jan 31, 2020 |
How does it compare nearby?
- Of the 2 hospitals CMS lists in Columbia County, 2 have an overall star rating from CMS: 1 rated 4 of 5, 1 rated 3 of 5.
- CMS rates this one 3 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| Columbus Community Hospital | 4 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.