CCN 525595

St Francis Home

33 Everett St, Fond du Lac, WI 54935 · Fond Du Lac County

Phone: (920) 923-7980
Ownership: Non profit - Corporation
Certified beds: 90
Residents per day: 79.5
Health citations: 26
Penalties: 0
Fines: 0 · $0
Map: Open location

Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Overall

CMS overall star rating in this file.

Health inspection

Compared with other homes in the state.

Staffing

Based on reported PBJ nurse hours.

Quality measures

Long-stay 4 · short-stay 5.

Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Staffing hours

Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.

Measure: This home; State; U.S.
Nurse aide: 2.22; 2.58; 2.32
LPN/LVN: 0.55; 0.64; 0.86
Registered nurse: 0.80; 0.99; 0.69
Total nurse staff: 3.57; 4.21; 3.86
Weekend total: 3.23; 3.77; 3.42
Weekend RN: 0.55; 0.68; 0.48

Adjusted total nurse hours: 4.10. Adjusted RN hours: 0.92. Case-mix total: 3.34. Case-mix index: 1.223.

Total nursing staff turnover: 54.1%. RN turnover: 66.7%. Administrators who left: 2.

How to read staffing hours

Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Fines and penalties

CMS reports 0 fines totaling $0, and 0 payment denials.

The Penalties file has no individual penalty rows for this CCN.

Cycle 1 standard survey: April 1, 2026. Health deficiencies counted in cycle 1: 5. Cycle 1 total health score: 36.

Cycle 2 standard survey: December 18, 2024. Cycle 2/3 health deficiencies: 16. Total weighted health survey score: 49.

Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Health inspection citations

The Health Deficiencies file lists 26 citations for this home, including 0 at immediate jeopardy and 0 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.

April 1, 2026

5 citations

Tag	What CMS cited	Scope and severity	Status
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 1	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 10, 2026
F607	Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 24, 2026
F692	Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 10, 2026
F698	Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 10, 2026
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 10, 2026

April 21, 2025

1 citation

Tag	What CMS cited	Scope and severity	Status
F609	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · May 16, 2025

December 18, 2024

10 citations

Tag	What CMS cited	Scope and severity	Status
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F558	Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F623	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F580	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F625	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. Resident Rights Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F641	Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 18, 2025
F692	Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F755	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F757	Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F759	Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025

July 29, 2024

2 citations

Tag	What CMS cited	Scope and severity	Status
F609	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 29, 2024
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 29, 2024

January 11, 2024

1 citation

Tag	What CMS cited	Scope and severity	Status
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 11, 2024

November 9, 2023

2 citations

Tag	What CMS cited	Scope and severity	Status
F609	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 9, 2023
F610	Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 9, 2023

September 13, 2023

5 citations

Tag	What CMS cited	Scope and severity	Status
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 3	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 13, 2023
F552	Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 13, 2023
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 13, 2023
F758	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. Pharmacy Service Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 13, 2023
F883	Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 13, 2023

Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Other facts in the provider file

Provider type: Medicare and Medicaid.
Chain name in the file: SSM Health (2 facilities). Chain average overall rating: 3.0.
Legal business name: St. Francis Home of Fond Du Lac Wisconsin INC.
First approved for Medicare and Medicaid services: July 1, 1996.
Resident and family council: Resident.
Automatic sprinklers in all required areas: Yes.
Add this home to a comparison

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Harbor Haven Health & Rehabilitation · overall 5
Edenbrook of Fond Du Lac · overall 4
Fond du Lac Lutheran Home · overall 3
Avina of Fond du Lac · overall 2
Avina on Division · overall 1

All nursing homes in Fond du Lac

Questions

What is the CMS overall rating for St Francis Home?

St Francis Home has an overall rating of 3 out of 5. The health inspection rating is 3, staffing is 3, and the quality measure rating is 4.

How many health citations does CMS list for St Francis Home?

The Health Deficiencies file lists 26 health citations for this home. 0 are coded immediate jeopardy (J, K, or L) and 0 are coded actual harm that is not immediate jeopardy (G, H, or I).

What nurse staffing does CMS report for St Francis Home?

CMS reports 3.57 total nurse hours per resident per day, including 0.80 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.

CMS file

Opening the record…

December 18, 2024

10 citations

Tag	What CMS cited	Scope and severity	Status
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F558	Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F623	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F580	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F625	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. Resident Rights Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F641	Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 18, 2025
F692	Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F755	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F757	Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025
F759	Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 31, 2025