Aurora Medical Ctr Oshkosh
An acute care hospital in Oshkosh, Wisconsin 54904
855 N Westhaven Drive, Oshkosh, Wisconsin 54904. (920) 456-6000.
- Medicare payments cut under the HAC Reduction Program (fiscal year 2026)
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The short answer
Record last released by CMS on Oct 20, 2026.
- 4of 5 CMS’s overall rating
- 4of 5 patient survey rating
- 1 deficiency cited in the last three years
- 84 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 Mar 27, 2026: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited Mar 2026. 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.
Mar 27, 2026: complaint inspection1 deficiency
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Rn Supervision Of Nursing Care
The inspectors’ words, 1,411 words
“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 29972 Surveyor: Jefferson, Claudette Based on record review and interview, staff failed to perform pain assessments/reassessments and provide effective pain interventions to ensure pain management needs are met in 4 of 10 medical records reviewed (Patient (Pt) #1, 2, 3, 7); and failed to evaluate vital signs as per policy in 4 of 10 medical records reviewed (Pt #1, 2, 3, 7), in a total sample of 10 medical records reviewed. Findings Include: Review of policy and procedure titled, “Pain Management Policy” last reviewed 09/09/2025 revealed: - “Patients will receive interventions that reduce or eliminate pain associated with their diagnosis, procedure or treatment and will be reassessed for the effectiveness of the intervention.” - “The nurse is to use appropriate valid and reliable evidence-based pain assessment tools and techniques that are developmentally, cognitively, and cultural sensitive (see attachment A).” - “Conduct a comprehensive pain assessment on admission or visit when pain is present and when there is any new report of patient pain or behaviors indicating pain.” - “The comprehensive assessment of pain includes, to the extent relevant to the individual patient circumstances, the following: a) Intensity, b) Location, radiation, c) Descriptor/quality, d) Aggravating and alleviating factors, e) Onset, F) Duration.” - “Document pain severity (intensity) utilizing an...appropriate pain scale...” Review of Attachment A titled, “Evidence Based Pain Scales...” last revised 09/23/2025 revealed: - “Labor Pain: Coping or Not Coping...Pain is an inherent part of labor. The perception of labor is influenced by one’s environment, experiences, emotions, social, and cultural factors. Labor pain is highly individualized and because of this, requires individualized and specialized assessment. Assessment may focus on level of coping rather than intensity of pain (Number Rating Scale).” - “Cues that a patient is not coping: a. Patient states they are not coping. b. Crying, tearfulness, wincing...c. breathing is ragged or strained. d. Expression of dread of contractions. e. Tremulous voice. f. Inability to focus or concentrate. g. Panicked or tensing during contractions...” - “Cues that a patient is coping: a. Patient states they are coping. b. Rhythmic activity or breathing during contractions. c. Patient behaves the same way during and between contractions. d. Calm facial expression. e. Focus inward. f. Able to relax during contractions. g. Attention focusing (vocalization, moaning, counting, chanting).” Review of Labor Maternal-Fetal Assessment-Attachment D (Attachment to Nursing Documentation Policy) last reviewed 03/28/2025 revealed: - Maternal Vital Signs including pulse (P), respirations (R), blood pressure (BP) are every hour while in active labor and/or on Oxytocin (medication to induce labor) and a temperature (T) every 2 hours. - Labor Pain Status-Coping/Not Coping assessments are every hour while in active labor (>/= 6 centimeters dilated), after administered Oxytocin (medication to induce labor), and/or after receiving an Epidural (spinal pain block). Review of Pt #1’s medical record revealed she presented to Labor and Delivery with uterine contractions and was admitted as an inpatient on 02/02/2026 at 10:31 AM; Pt #1 was discharged on 02/08/2026 at 11:00 AM. Pt #1 received an epidural (spinal pain block) at 12:55 PM and 5:10 PM and was determined to be in active labor on 02/02/2026 at 2:38 PM. Pt #1 delivered the baby via cesarean section (c-section) on 02/03/2026 at 5:48 AM. Review of Pt #1’s nursing Labor Pain flowsheets revealed: -Nursing staff assessed pain on 02/02/2026 at 12:00 PM and then not again until 2:00 PM (2 hours later); not every hour as per policy. -Nursing staff assessed pain on 02/02/2026 at 11:27 PM and then not again until 02/03/2026 at 1:30 AM (2 hours and 3 minutes later). -Nursing staff assessed pain on 02/03/2026 at 1:30 AM and then not again until 5:36 AM (4 hours and 6 minutes later), at which time documentation in the Pain/Comfort Interventions category revealed, “Unacceptable--administer scheduled/PRN (as needed) interventions.” Pain Documentation at 5:36 AM, did not include the “Type of Pain” and if Pt #1 was Coping/Not Coping as per policy (Pt #1 delivered the baby via c-section at 5:48 PM). Review of Pt #1’s Vitals flowsheets revealed: -Nursing staff assessed respirations on 02/02/2026 at 7:00 PM and than not again until 9:02 PM (2 hours and 2 minutes later); not every hour as per policy. -Nursing staff assessed respirations on 02/02/2026 at 9:02 PM and then not again until 02/03/2026 at 12:44 AM (3 hours and 42 minutes later). -Nursing staff assessed respirations on 02/03/2026 at 12:44 AM and then not again until 9:31 AM (9 hours and 13 minutes later). Review of Pt #2’s medical record revealed she presented to Labor and Delivery with uterine contractions and was admitted as an inpatient on 01/05/2026 at 05:18 AM; Pt #2 was discharged on 01/08/2026 at 2:03 PM. Pt #2 received an epidural on 01/05/2026 at 12:33 PM and was determined to be in active labor on admission. Review of Pt #2’s Labor Pain flowsheets revealed: -Nursing staff assessed pain on 01/05/2026 at 7:30 AM and then not again until 9:30 AM (2 hours later); not every hour as per policy. -Nursing staff assessed pain on 01/05/2026 at 3:30 PM and then not again until 5:30 PM (2 hours later). -Nursing staff assessed pain on 01/05/2026 at 5:30 PM and then not again before being transferred to the operating room for a c-section at 10:17 PM (4 hours and 47 minutes). Review of Pt #2’s Vitals flowsheets revealed: -Nursing staff assessed vital signs on 01/05/2026 at 5:00 AM than not again until 6:45 AM (1 hours and 45 minutes later); not every hour as per policy. -Nursing staff assessed vital signs on 01/05/2026 at 9:40 AM than not again until 11:55 AM (2 hours and 15 minutes later). -Nursing staff assessed vital signs on 01/05/2026 at 6:45 PM and then not again before being transferred to the operating room for a c-section at 10:17 PM (3 hours and 32 minutes). -Nursing staff assessed respirations on 01/05/2026 at 11:55 AM than not again until 6:35 PM (6 hours and 40 minutes later); not every hour as per policy. Review of Pt #3’s medical record revealed she presented to Labor and Delivery for an elective induction of labor on 02/07/2026 at 3:07 PM; Pt #3 was discharged on 02/11/2026 at 7:42 PM. Pt #3 and was determined to be in active labor on 02/08/2026 at 4:09 AM. Review of Pt #3’s Labor Pain flow sheets revealed: -There was no documented evidence of nursing staff assessing pain from 02/08/2026 at 4:09 AM (active labor) until 7:30 AM (3 hours and 21 minutes later). -Nursing staff assessed pain on 02/08/2026 at 4:00 PM and then not again until 02/09/2026 at 12:00 AM (8 hours later); not every hour as per policy. Review of Pt #3’s Vitals flow sheets revealed: -There was no documented evidence of nursing staff assessing respirations from 02/08/2026 at 4:09 AM (active labor) until 7:00 AM (2 hours and 51 minutes later); not every hour as per policy -Nursing staff assessed respirations on 02/08/2026 at 7:00 AM than not again until 9:30 AM (2 hours and 30 minutes later). -Nursing staff assessed respirations on 02/08/2026 at 9:30 AM than not again until 12:00 PM (2 hours and 30 minutes later). -There was no documented evidence of nursing staff assessing respirations from 02/08/2026 at 5:30 PM to 02/09/2026 at 3:30 AM (10 hours later). Review of Pt #7’s medical record revealed she presented to Labor and Delivery with uterine contractions and was admitted as an inpatient on 03/09/2026 at 10:01 PM; Pt #7 was discharged on 03/11/2026 at 12:20 PM. Pt #7 received an epidural on 03/09/2026 at 11:53 PM and was determined to be in active labor on 03/10/2026 at 1:00 AM. Review of Pt #7’s Labor Pain flow sheets revealed: -There was no documented evidence of nursing staff assessing pain during labor from 03/09/2026 at 8:00 PM and 03/10/2026 at 5:31 AM (time of delivery) (9 hours and 31 minutes). Review of Pt #7’s Vitals flow sheets revealed: -There was no documented evidence of nursing staff assessing respirations during labor from 03/09/2026 at 11:51 PM (epidural started) to 03/10/2026 at 5:31 AM (time of delivery) (5 hours and 40 minutes). During interview with Educator E on 03/27/2026 beginning at 10:00 AM, Educator E stated that nursing staff should follow the policy for pain assessments and vital signs and this should be documented in the flowsheets.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Mar 27, 2026 | Complaint inspection | 1 deficiency 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 4 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 6; safety of care, 0 better and 0 worse of 5; readmission, 0 better and 0 worse of 8.
- Patients rate it 4 of 5 in CMS’s patient survey (700 surveys completed, Oct 1, 2024 to Sep 30, 2025): 75% rated it 9 or 10 out of 10, and 77% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), no different than national benchmark; catheter urinary tract infections (CAUTI), no different than national benchmark; 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 attack 10.9%, heart failure 11%, pneumonia 17.2%, COPD 9.8%, stroke 11.3%. 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 attack 13.8%, heart failure 19.7%, pneumonia 17%, COPD 19.1%. 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; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 122 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 0% left before being seen.
- 70% 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 | 4 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 4 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Dec 6, 2003.
- Ownership: voluntary non-profit - private.
- It is accredited by DNV, 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.
- CMS cut its Medicare payments by 1% for fiscal year 2026 under the Hospital-Acquired Condition Reduction Program, which does so for the quarter of hospitals that fare worst on conditions patients get in hospital.
- 1 deficiency cited in the last three years came from an inspection 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.
| Date | What | Detail |
|---|---|---|
| Medicare payment reduction (HAC Reduction Program) | Fiscal year 2026: 1% of Medicare payments |
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 5 of 5.
- 86% 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?
- Advocate Aurora Health, Inc. and Aurora Health Care, Inc. and Advocate Health Inc. and Aurora Health Care North Inc. run it.
- 11 owners or officers are people: Gabrielle Finley-Hazle (corporate officer); Gabrielle Finley-Hazle (corporate director); Tori Munnik (corporate officer, 0%); Tori Munnik (managing employee (on the payroll), 0%); Rachelle Hart (corporate officer); Kara Richardson (corporate officer, 0%); Lindsay Durgin (corporate officer, 0%); Holly Schmidtke (corporate officer); Rachel Halverson (corporate officer); Desiree Millet (corporate officer, 0%); Desiree Millet (managing employee (on the payroll), 0%).
- CMS’s Provider of Services file records no change 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 |
|---|---|---|---|
| Advocate Aurora Health, Inc. | Owns 5% or more through other companies | 100% | Apr 1, 2018 |
| Advocate Aurora Health, Inc. | Runs it (operational or managerial control) | 100% | Apr 1, 2018 |
| Aurora Health Care, Inc. | Owns 5% or more through other companies | Oct 27, 2003 | |
| Aurora Health Care, Inc. | Runs it (operational or managerial control) | Oct 27, 2003 | |
| Advocate Health Inc. | Runs it (operational or managerial control) | Dec 2, 2022 | |
| Aurora Health Care North Inc. | Owns 5% or more through other companies | Sep 14, 2010 | |
| Aurora Health Care North Inc. | Runs it (operational or managerial control) | Sep 14, 2010 |
How does it compare nearby?
- Of the 4 hospitals CMS lists in Winnebago County, 2 have an overall star rating from CMS: 2 rated 4 of 5.
- CMS rates this one 4 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| Thedacare Regional Med Ctr - Neenah | 4 |
| Childrens Hospital of Wisconsin Fox Valley | Not given |
| Winnebago Mental Health Institute | Not given |
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.