Cycle 1
Health 2024-12-18 · Fire 2024-12-18
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fond Du Lac, WI
St Francis Home
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
33 Everett St, Fond Du Lac, WI
(920) 923-7980
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
72
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ssm Health
Operator or chain grouping
Approved since
1996-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
2 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
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
0.88
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.82
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.48
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
4.41
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,559
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9924
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.31
Performance 18.51% · Measure score 6.31 · Achievement 6.31 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.02
Baseline 8.38% · Performance 6.85% · Measure score 4.02 · Achievement 3.29 · Improvement 4.02
Total nurse turnover
3.22
Baseline 55.06% · Performance 50.51% · Measure score 3.22 · Achievement 3.22 · Improvement 1.01
Adjusted total nurse staffing
2.23
Baseline 4.27 hours · Performance 3.71 hours · Measure score 2.23 · Achievement 2.23 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.9% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 6.82% · Lower 95% interval 6.11% |
| Discharge to community | 55.28% |
50.57%
4.7 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 53.09% · Lower 95% interval 44.87% |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 64 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 55.56% |
53.69%
1.9 pts better
|
Numerator 30 · Denominator 54 |
| Discharge mobility score | 31.48% |
50.94%
19.5 pts worse
|
Numerator 17 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 2 · Denominator 64 · Adjusted rate 4.07% |
| Healthcare-associated infections requiring hospitalization | 6.85% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 5.17% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 4.23% |
8.2%
4 pts worse
|
Numerator 8 · Denominator 189 |
| Staff flu vaccination coverage | 96.48% |
42%
54.5 pts better
|
Numerator 192 · Denominator 199 |
| Discharge function score | 51.85% |
56.45%
4.6 pts worse
|
Numerator 28 · Denominator 54 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 16 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.6 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.2
0.5 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.2 · Expected 1.1 · 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 | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.2%
0.1 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.8% · Q3 2.8% · Q4 1.6% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
5.0%
3.1 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.5% · Q4 5.1% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
4.9%
3.9 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.1% |
16.6%
7.5 pts worse
|
19.6%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 27.1% · Q3 24.5% · Q4 26.4% · 4Q avg 24.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
16.7%
7.3 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 9.5% · Q3 8.7% · Q4 11.4% · 4Q avg 9.4% · 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 | 20.7% |
21.1%
0.4 pts better
|
16.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 15.0% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.6% |
17.3%
4.7 pts better
|
14.9%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 22.2% · Q3 7.8% · Q4 12.0% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
2.3%
1.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 1.8% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
3.0%
0.6 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 1.4% · Q3 1.4% · Q4 7.8% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.2% |
25.5%
9.7 pts worse
|
19.8%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.8% · Q2 36.4% · Q3 34.4% · Q4 27.4% · 4Q avg 35.2% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.5%
0.3 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 9.9% · Q3 6.4% · Q4 1.3% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
86.8%
11.3 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.1% · Q3 97.4% · Q4 100.0% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.7% |
15.0%
9.3 pts better
|
12.0%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.7% · Observed 4.8% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
82.2%
14.2 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.5% |
22.7%
2.2 pts better
|
23.9%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 16.1% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-13 · Fire 2023-09-13
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-10-05 · Fire 2022-10-05
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-18
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-18
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-02-03
E · Potential for more than minimal harm
2024-12-18
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-01-18
E · Potential for more than minimal harm
2024-12-18
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2025-01-18
E · Potential for more than minimal harm
2024-12-18
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-01-18
F · Potential for more than minimal harm
2023-09-13
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-09-13
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-11-08
E · Potential for more than minimal harm
2023-09-13
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-02-27
E · Potential for more than minimal harm
2023-09-13
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-13
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-09-13
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 2023-09-15
D · Potential for more than minimal harm
2023-09-13
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-09-15
F · Potential for more than minimal harm
2022-10-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-10-05
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-11-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-21
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 2025-05-16
F · Potential for more than minimal harm
2024-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-18
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-18
D · Potential for more than minimal harm
2024-12-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-07-29
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 2024-08-29
D · Potential for more than minimal harm
2024-07-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-01-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-11
D · Potential for more than minimal harm
2023-11-09
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 2023-12-09
D · Potential for more than minimal harm
2023-11-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-09
F · Potential for more than minimal harm
2023-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-13
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-13
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-07-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-08-02
D · Potential for more than minimal harm
2023-07-10
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 2023-08-02
D · Potential for more than minimal harm
2023-07-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-02
D · Potential for more than minimal harm
2022-10-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-10-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-10-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-05
Penalties and ownership
What sits behind the stars
Ownership
Agnesian Healthcare Inc
Operational/Managerial Control · Organization
Anderson, Sue
Operational/Managerial Control · Individual
Briscoe, David
Operational/Managerial Control · Individual
Briscoe, Patricia
Operational/Managerial Control · Individual
Gloede, Denise
Operational/Managerial Control · Individual
Gloede, Denise
Corporate Officer · Individual
Health Dimensions Consulting Inc
Operational/Managerial Control · Organization
Krueger, Kari
Operational/Managerial Control · Individual
Krueger, Kari
Corporate Officer · Individual
Quednow, Dawn
Operational/Managerial Control · Individual
Radina, Victor
Operational/Managerial Control · Individual
Radina, Victor
Corporate Officer · Individual
Rogotzke, Amber
Operational/Managerial Control · Individual
Shvetzoff Hennessey, Erin
Operational/Managerial Control · Individual
Shvetzoff, Sergei
Operational/Managerial Control · Individual
Shvetzoff, Tami
Operational/Managerial Control · Individual
Smith, Kevin
Corporate Director · Individual
Smith, Kevin
Corporate Officer · Individual
Ssm Health Care Corporation
Operational/Managerial Control · Organization
Ssm Health Care Of Wisconsin Inc
Operational/Managerial Control · Organization
Walkup, James
Corporate Director · Individual
Walkup, James
Corporate Officer · Individual
Weber, Lisa
Operational/Managerial Control · Individual
Wilson, Amy
Operational/Managerial Control · Individual
Wilson, Amy
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Harbor Haven Health & Rehabilitation
Fond Du Lac, WI
5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
#2
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
#3
Avina of Fond du Lac
Fond Du Lac, WI
2-star overall rating with 2-star inspections with $7,446 in total fines with 14 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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