Childrens Hospital of Wisconsin Fox Valley
A children’s hospital in Neenah, Wisconsin 54956
130 Second St, Neenah, Wisconsin 54956. (920) 969-7900.
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The short answer
Record last released by CMS on Oct 20, 2026.
- Not rated CMS’s overall rating
- Not rated patient survey rating
- 2 deficiencies cited in the last three years (needs attention)
- 42 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- 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.
- Condition-level deficiency
- 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.
What did inspectors find?
The last inspection on record was on Feb 5, 2025: a complaint inspection.
2 deficiencies cited in the last three years, 1 of them at condition level, the most serious.
1 deficiency at condition level, the more serious of CMS’s two levels
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
2 deficiencies in 1 month of the last 36. Last cited Feb 2025. Most serious: Condition-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.
Feb 5, 2025: complaint inspection2 deficiencies
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Medical Staff
The inspectors’ words, 242 words
“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 47413 Based on record review and interview, the facility failed to implement a comprehensive process to ensure contracted medical staff who provide on-call surgical coverage are appropriately privileged and credentialed to provide care in 6 of 14 privileging files reviewed (Surgeons B, F, L, P, Q, R, S). The facility failed to implement a comprehensive process to ensure contracted medical staff who provide on-call surgical coverage are appropriately privileged and credentialed to provide care. See Tag A-0341. Immediate Jeopardy was determined on 02/05/2025 at 2:18 PM under 42 CFR 482.22 regarding the facility’s failure to ensure contracted medical staff who provide on-call surgical coverage were privileged and credentialed. Facility staff were notified of the Immediate Jeopardy on 02/05/2025 at 2:35 PM. The Immediate Jeopardy began on 05/09/2022 and was removed on 02/05/2025 at 3:10 PM after the facility developed a process and educated identified individuals (Executive Director H and ACMO K) responsible for reviewing on-call schedules to confirm medical staff hold current privileges on a daily basis. All medical staff held privileges at the time of the survey. The deficient practice remains at a Condition level pending evidence of ongoing sustainable and systemic implementation of corrective actions.”
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Medical Staff Credentialing
The inspectors’ words, 652 words
“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 50644 Based on record review and interview, the facility failed to implement a comprehensive process to ensure contracted medical staff who provide on-call pediatric surgical coverage are appropriately privileged and credentialed to provide pediatric care in 6 of 14 privileging files reviewed (Surgeons B, E, F, L, P, Q,). Findings Include: A review of “Master Agreement between Theda Care, Inc. and Children’s Hospital of Wisconsin Inc. for Pediatric and Neonatal Program Services” revealed, “ ... 3.3-1 ... Children’s Convenance: (B). Any such physician practicing within the premises shall be a member in good standing of the medical staff of Children’s Hospital of Wisconsin- Fox Valley with appropriate privileges ...” Surgeon F started providing on-call pediatric surgical coverage on 10/09/2024. Review of Surgeon F’s privileging file revealed he was granted privileges on 01/09/2025, nearly 3 months later. Review of the facility’s on-call general surgery schedule revealed Surgeon F was the only surgeon on-call for 18 instances during the time period he was not privileged. There was no evidence that Surgeon F performed surgery during this time. Surgeon Q’s on-staff date was 01/03/2024. Review of Surgeon Q’s privileging file revealed he was granted privileges on 02/22/2024 nearly 1.5 months later. Review of the facility’s on-call general surgery schedule revealed Surgeon Q was the only surgeon on-call for 5 instances during the time period he was not privileged. There was no evidence that Surgeon Q performed surgery during this time. Surgeon P’s on-staff date was 10/11/2023. Review of Surgeon P’s privileging file revealed he was granted privileges on 12/07/2023 nearly 2 months later. Review of the facility’s on-call general surgery schedule revealed Surgeon P was the only surgeon on-call for 2 instances during the time period he was not privileged. There was no evidence that Surgeon P performed surgery during this time. Surgeon L’s on-staff date was 11/07/2022. Review of Surgeon L’s privileging file revealed he was granted privileges on 03/01/2023, nearly 4 months later. Review of the facility’s on-call general surgery schedule revealed Surgeon L was the only surgeon on-call for 4 instances during the time period he was not privileged. There was no evidence that Surgeon L performed surgery during this time. Surgeon B’s on-staff date was 05/09/2022. Review of Surgeon B’s privileging file revealed he was not granted permanent pediatric privileges until 10/30/2023. Review of the facility’s on-call general surgery schedule revealed Surgeon B was the only surgeon on-call for 13 instances during the time period he was not privileged. Surgeon E’s on-staff date was 04/20/2020. Review of Surgeon E’s privileging file revealed he was granted privileges on 06/29/2023, nearly 38 months later. Review of the facility’s on-call general surgery schedule revealed Surgeon E was the only surgeon on-call for 6 instances during the time period he was not privileged. There was no evidence that Surgeon E performed surgery during this time. During an interview on 02/04/2025 at 1:27 PM with CMO (Chief Medical Officer) M, CMO M stated, “We know this is an issue ... There is supposed to be an alert that goes off if there is a chart from Hospital A opened by a non-privileged provider. It did not alert in this case. The process fell through.” During an interview on 02/04/2025 at 3:55 PM with Executive Director H, Executive Director H stated that pediatric privileging would be part of Hospital A’s privileging process.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Feb 5, 2025 | Complaint inspection | 2 deficiencies cited |
How do patients fare?
- CMS gives no 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.: “Data are shown only for hospitals that participate in the Inpatient Quality Reporting (IQR) and Outpatient Quality Reporting (OQR) programs.”
- CMS gives no 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.: “Data are shown only for hospitals that participate in the Inpatient Quality Reporting (IQR) and Outpatient Quality Reporting (OQR) programs.”
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 | Not rated |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | Not rated |
Is it certified, and in good standing?
- Medicare-certified children’s hospital since Mar 14, 2001.
- Ownership: voluntary non-profit - other.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- Cited at 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. in the last three years: it didn’t meet a whole condition of Medicare’s rules for hospitals.
- Voluntary non-profit - Other.
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’s HAC Reduction Program file has no result for it: the program covers general acute care hospitals Medicare pays under its inpatient prospective payment system.
- 2 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.
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- 43 owners or officers are people: Kelly Grebe (corporate director); Rolando Rodriguez (corporate director, 0%); Phoebe Williams (corporate director); Timothy J Martin (corporate director); Eve Hall (corporate director); Mark A Cadieux (corporate director); Mark A Cadieux (managing employee (on the payroll)); James G Simaras (corporate officer, 0%); James G Simaras (managing employee (on the payroll), 0%); Patrick Hammes (corporate director); Jason Jarzembowski (corporate director); Todd Adams (corporate director); Nancy Korom (corporate officer); Christopher Kaltenbach (corporate director); Mark Witt (corporate director); Thomas Arenberg (corporate director); Paul Knoebel (corporate director); Jamie Purko (corporate director); Linda Benfield (corporate director); Margaret N Troy (corporate officer); Margaret N Troy (corporate director); Margaret N Troy (managing employee (on the payroll)); Thomas Precia (corporate director); Christina Chang (corporate director); David Margolis (corporate director); John Reichert (corporate director); Kenneth Bockhorst (corporate director); Monica Ricca (corporate officer); Monica Ricca (managing employee (on the payroll)); Benjamin Blanton Melson (corporate director); Todd Endres (corporate director); Keith T Oldham (corporate director); Dave Werner (corporate director); Nancy Avila (corporate director); Craig Duncan (managing employee (on the payroll)); Michelle Gass (corporate director); Matthew D’attilio (corporate director); Michael Gutzeit (corporate officer); James Popp (corporate director); Tim Gerend (corporate director); Gail Ostrander (corporate officer, 0%); Gail Ostrander (managing employee (on the payroll), 0%); Joseph Gehrke (corporate director).
- 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.
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 gives this hospital no overall star rating to compare.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| Thedacare Regional Med Ctr - Neenah | 4 |
| Aurora Medical Ctr Oshkosh | 4 |
| 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.
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.