01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-04-01 | 5 | 2026-04-01 | 7 |
| Cycle 2 | 2024-12-18 | 11 | 2024-12-18 | 7 |
| Cycle 3 | 2023-09-13 | 10 | 2023-09-13 | 7 |
CMS CCN 5255952026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
St Francis Home
33 Everett St · Fond Du Lac, WI 54935 · Fond Du Lac County
Certified beds90CMS provider file
Recent citation rows47current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
47 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-01 · HEALTHF0607Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2026-04-242026-04-01 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2026-04-102026-04-01 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2026-04-102026-04-01 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-04-102026-04-01 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-04-102026-04-01 · FIREK0132Severity E · pattern; potential for more than minimal harm
Construction Deficiencies
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Correction field: Deficient, Provider has date of correction · 2026-04-202026-04-01 · FIREK0271Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have exits that are accessible at all times.
Correction field: Deficient, Provider has date of correction · 2026-05-012026-04-01 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-04-202026-04-01 · FIREK0712Severity C · widespread; potential for minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2026-04-202026-04-01 · FIREK0753Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of highly flammable decorations.
Correction field: Deficient, Provider has date of correction · 2026-04-202026-04-01 · FIREK0914Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Correction field: Deficient, Provider has date of correction · 2026-04-302026-04-01 · FIREK0923Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2026-04-202025-04-21 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-05-16 · complaint2024-12-18 · HEALTHF0558Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2025-01-312024-12-18 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2025-01-312024-12-18 · HEALTHF0623Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Correction field: Deficient, Provider has date of correction · 2025-01-312024-12-18 · HEALTHF0625Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-01-312024-12-18 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-01-182024-12-18 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2025-01-312024-12-18 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-01-312024-12-18 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2025-01-312024-12-18 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2025-01-312024-12-18 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-01-312024-12-18 · FIREK0211Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2025-01-3103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- ANDERSON, SUEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/28/2022
- BASS, PAIGEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2025
- BEARDMORE, DANIELIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/12/2024
- BELL, JUDITHIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2023
- BROWN, MARYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/04/2018
- BURNETT, JANICEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2022
- CORCORAN, RICKIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/01/2017
- DEVLIN, MARIEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/01/2018
- DOLAN, PETERIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2024
- EMMER, RHEAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/28/2022
- GLOEDE, DENISEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2024
- HARDT, JOHNIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2022
- HARTENBACH, DAVIDIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2025
- HER, PENGIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 12/13/2023
- HOLZMAN, MARKIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 12/13/2023
- IMHOLZ, DONALDIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/01/2018
- KAISER, LAURAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2017
- KARSTEN, JOANIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/11/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.57per resident day
RN hours0.80per resident day
Weekend nurse hours3.23per resident day
Staff turnover54.1%CMS reported field
06 / LOCAL RECORDS
Open the Fond Du Lac ledger →Other published facilities nearby
Avina Of Fond Du Lac50 beds · CMS overall 2/562 citation rowsAvina On Division50 beds · CMS overall 1/571 citation rowsEdenbrook Of Fond Du Lac90 beds · CMS overall 4/536 citation rowsFond Du Lac Lutheran Home85 beds · CMS overall 3/589 citation rowsHarbor Haven Health & Rehabilitation85 beds · CMS overall 5/521 citation rows