Federal inspection record · CMS data as of October 1, 2026
St Francis Home
33 Everett St, Fond du Lac, WI · (920) 923-7980
- Certified beds
- 90
- Residents per day
- 76
- Ownership
- Non-Profit
- Chain
- Ssm Health
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- July 1, 1996
1
How this home got 3 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Wisconsin.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Wisconsin homes
St Francis Home carries 49 inspection points. That is fewer than 57% of Wisconsin's 321 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Wisconsin: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–11 pts
- 4★ 11–37 pts
- 3★ 37–76 pts
- 2★ 76–130.75 pts
- 1★ over 130.75 pts
Bars show every rated home in Wisconsin by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
26 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Quality of Life and Care6E
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Freedom from Abuse, Neglect, and Exploitation5E
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Resident Rights5E
- E
Reasonably accommodate the needs and preferences of each resident.
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Infection Control4F
- D
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Pharmacy Service4D
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
Ensure medication error rates are not 5 percent or greater.
- D
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.
Nutrition and Dietary1F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Assessment and Care Planning1D
- D
Ensure each resident receives an accurate assessment.
Inspection history
2026-04-01
5 health deficiencies · 7 fire-safety deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2024-12-18
11 health deficiencies · 7 fire-safety deficiencies
Top issue: Resident Rights (4 deficiencies)
2023-09-13
10 health deficiencies · 7 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 33 min of nursing staff time a day, 54 min of it from a registered nurse.
This home
3 h 33 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 61% of nursing staff and 61% of registered nurses left in the past year, along with 2 administrators.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.7 pts worse | 2.3 | 1.6 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1.1 pts better | 1.1 | 2.2 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine2.5 pts better | 98.5% | 96.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine1.2 pts worse | 94.4% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.4 pts better | 1.9% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms3.2 pts better | 2.8% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.1 pts better | 2.8% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication6.6 pts worse | 23.4% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication3.8 pts better | 12.1% | 15.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened6.7 pts worse | 23.7% | 17.0% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased0.4 pts better | 15.4% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.1 pts worse | 3.0% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.4 pts worse | 4.1% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence3.4 pts worse | 27.0% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.8 pts better | 3.1% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine12.5 pts better | 99.4% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit10.7 pts better | 4.9% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.7 pts better | 0.5% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine4.4 pts better | 86.6% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admissionAbout the same | 22.5% | 22.5% | 23.4% |
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Who owns and runs it
57 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Agnesian Healthcare Inc | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Anderson, Sue | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Anderson, Sue | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Bass, Paige | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Beardmore, Daniel | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Bell, Judith | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Brown, Mary | Managing Control - Governing Body · Individual | 0% | 5 facilities |
| Burnett, Janice | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Corcoran, Rick | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Devlin, Marie | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Dolan, Peter | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Emmer, Rhea | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Gloede, Denise | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Gloede, Denise | Corporate Officer · Individual | 0% | 1 facilities |
| Gloede, Denise | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Hardt, John | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Hartenbach, David | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Her, Peng | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Holzman, Mark | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Imholz, Donald | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Kaiser, Laura | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| Karsten, Joan | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Kindle, Carolyn | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Krueger, Kari | Corporate Officer · Individual | 0% | 1 facilities |
| Krueger, Kari | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Leitzen Fye, Patti | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Mabry, Jennifer | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Mabry, Jennifer | Adp Of The SNF · Individual | 0% | 1 facilities |
| Maskel, Jennifer | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Matzke, Wayne | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Nairn, Thomas | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Otte, Olivia | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Pandl, Mary | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Pogodzinski, Matthew | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Radina, Victor | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Radina, Victor | Corporate Officer · Individual | 0% | 1 facilities |
| Radina, Victor | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Ross, Samuel | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Smith, Kevin | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| Smith, Kevin | Corporate Director · Individual | 0% | 2 facilities |
| Smith, Kevin | Corporate Officer · Individual | 0% | 2 facilities |
| Sparkman, Wesley | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Ssm Health Care Corporation | Operational/Managerial Control · Organization | 0% | 2 facilities |
| Ssm Health Care Corporation | Adp Of The SNF · Organization | 0% | 2 facilities |
| Ssm Health Care Of Wisconsin Inc | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Ssm Health Care Of Wisconsin Inc | Adp Of The SNF · Organization | 0% | 1 facilities |
| Valdez, Joseph | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Valdivia, Tomas | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Walkup, James | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Walkup, James | Corporate Director · Individual | 0% | 1 facilities |
| Walkup, James | Corporate Officer · Individual | 0% | 1 facilities |
| Weber, Lisa | Operational/Managerial Control · Individual | 0% | 8 facilities |
| Weber, Lisa | Adp Of The SNF · Individual | 0% | 8 facilities |
| Whalen, James | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Wilson, Amy | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| Wilson, Amy | Corporate Officer · Individual | 0% | 2 facilities |
| Wilson, Amy | Operational/Managerial Control · Individual | 0% | 2 facilities |
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Fire safety
21 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Egress6E
- E
Have exits that are accessible at all times.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E
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.
- E
Install proper backup exit lighting.
- E
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.
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Gas, Vacuum, and Electrical Systems5F
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- D
Have proper medical gas storage and administration areas.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Have power receptacles that are properly grounded.
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Smoke4E
- D
Inspect, test, and maintain automatic sprinkler systems.
- E
Have an enclosure around a vertical opening shaft.
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Construction2E
- E
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
Miscellaneous2E
- E
Have restrictions on the use of highly flammable decorations.
- C
Have simulated fire drills held at unexpected times.
Emergency Preparedness1F
- F
Conduct risk assessment and an All-Hazards approach.
Services1D
- D
Install properly constructed and protected linen or trash chutes.
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Other homes nearby
-
Harbor Haven Health & Rehabilitation
Fond du Lac, WI
★★★★★- Worst citation, 3 yrs
- D
- Nursing / resident / day
- 4 h 25 min
- Fines
- $0
-
Avina on Division
Fond du Lac, WI · Avina Healthcare
★★★★★- Worst citation, 3 yrs
- L
- Nursing / resident / day
- 3 h 37 min
- Fines
- $58,210
-
Avina of Fond du Lac
Fond du Lac, WI · Avina Healthcare
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 4 h 7 min
- Fines
- $7,446