Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ST FRANCIS HEALTH SERVICES
SAINT FRANCIS, WI · 34 certified beds · Last Life Safety survey February 18, 2026
CMS Certification Number 525477 · first certified November 1991
Ownership
Operated by NORTH SHORE HEALTHCARE · For profit - Corporation
- Ownership changed April 4, 2017 (change of ownership)from BEVERLY ENTERPRISES - WISCONSIN INC
Position within WI
19 citations — more than 54% 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 5 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 March 2027 — about 6 months from now. This facility’s last Life Safety survey was February 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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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 19 citations on file are 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)
3 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 19 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 | 19 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 1, 2024 | 8 |
| April 10, 2025 | 6 |
| February 18, 2026 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-02-18 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2026-02-18 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 2 | 2026-02-18 |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 2 | 2025-04-10 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2024-02-01 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2024-02-01 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2025-04-10 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2026-02-18 |
What the citations cover
- Smoke Deficiencies 7
- Egress Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Emergency Preparedness Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Egress Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 18, 2026 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (April 10, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 20, 2026) |
April 10, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Waiver has been granted |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (May 9, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 9, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 9, 2025) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (May 9, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 9, 2025) |
February 1, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (February 23, 2024) |
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (February 23, 2024) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Waiver has been granted (February 26, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (February 20, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 21, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (February 26, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (February 20, 2024) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (February 27, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.