Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
St Francis Home
Fond du Lac, WI · 90 certified beds · Last Life Safety survey April 1, 2026
CMS Certification Number 525595 · first certified July 1996
Ownership
Operated by SSM HEALTH · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WI
21 citations — more than 62% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 7 citations; the earlier surveys in the window averaged 7. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens May 2027 — about 7 months from now. This facility’s last Life Safety survey was April 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
1 of the 21 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 21 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 21 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 13, 2023 | 7 |
| December 18, 2024 | 7 |
| April 1, 2026 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0222 | 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. | 2 | 2024-12-18 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 2 | 2026-04-01 |
| K-0281 | Install proper backup exit lighting. | 1 | 2024-12-18 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2026-04-01 |
| K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | 1 | 2024-12-18 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2026-04-01 |
| K-0541 | Install properly constructed and protected linen or trash chutes. | 1 | 2023-09-13 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2024-12-18 |
What the citations cover
- Egress Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Smoke Deficiencies 4
- Construction Deficiencies 2
- Other 4
| Category | Citations |
|---|---|
| Egress Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Smoke Deficiencies | 4 |
| Construction Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 1, 2026 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Deficient, Provider has date of correction (April 20, 2026) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (May 1, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 20, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 20, 2026) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (April 20, 2026) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (April 30, 2026) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (April 20, 2026) |
December 18, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0222 | 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. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (February 3, 2025) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (January 18, 2025) |
| K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Deficient, Provider has date of correction (January 18, 2025) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (January 18, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 31, 2025) |
September 13, 2023 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Waiver has been granted (February 27, 2024) |
| K-0222 | 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. | Deficient, Provider has date of correction (October 20, 2023) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (September 15, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 15, 2023) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (September 15, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (November 8, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.