Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Francis Home during CMS and state inspections, most recent first.
Food Items Stored Without Required Date Marking: Surveyors found multiple dry storage, cooler, and freezer items without required open or use-by dates, including bulk ingredients, prepared foods, and frozen entrees. The FNSD stated the facility follows the WI Food Code and later confirmed many of the items should have been date marked, but was unsure of the dates for several foods and said one item should be discarded. The deficiency had the potential to affect all residents in the facility.
Missing Employee Reference Checks: The facility did not ensure its abuse policy was followed for 2 employees reviewed for onboarding records. A surveyor found that two CNAs had background check files that did not include reference checks, even though the facility's policy requires background, reference, and credential checks for potential employees. The NHA confirmed the reference checks should have been completed.
A resident with ESRD on dialysis and CHF had physician orders for daily or post-dialysis weights and for provider notification if weight increased by 3 lbs in one day or 5 lbs in one week. The resident’s record had missing weight and fluid-restriction documentation, and recorded weights showed multiple one-day gains above the notification threshold. RN and DON staff confirmed the physician should have been updated about the weight increases.
Missing Dialysis Access Monitoring and Pre-Treatment Documentation: A resident receiving hemodialysis had missing TAR documentation for pre-treatment dialysis forms and AV fistula monitoring, including bruit, thrill, and site checks. The resident had ESRD, dialysis dependence, and CHF, and the DON and RNS confirmed the required orders should have been completed and documented.
Infection prevention and control was not maintained for residents on EBP. Staff failed to wear required gowns and gloves during direct care and high-contact activities for residents with indwelling catheters and wounds, including catheter care, colostomy care, insulin administration, and therapy transfers. One resident’s room lacked an EBP sign, and another resident’s care plan did not identify EBP. Staff and leadership acknowledged the missed PPE use and the missing EBP communication.
The facility did not report an allegation of misappropriation of narcotic contingency medications to the State Agency after staff discovered missing doses of controlled substances. Although the incident was reported to local law enforcement and internal procedures were changed, the required notification to the SA was not made, potentially affecting residents who may have needed those medications.
A long-term care facility failed to maintain an effective infection prevention and control program, impacting eight residents and potentially all 74 residents. The facility's line list for a Norovirus outbreak was inaccurate, and staff did not adhere to Enhanced Barrier Precautions (EBP) for residents requiring such measures. PPE was not consistently available or used, and there was confusion among staff regarding residents' precaution statuses, indicating a lack of proper training and oversight.
The facility failed to ensure call lights were within reach for several residents dependent on staff for mobility and care. Observations revealed call lights were inaccessible, either wrapped around nightstand handles, hanging on drawers, or placed across the room. Staff acknowledged the issue and repositioned the call lights. The residents had conditions like Alzheimer's and physical impairments, making them reliant on staff assistance.
The facility failed to provide written transfer notices to a resident and their POA for a hospital transfer and did not notify the Ombudsman of hospital transfers for six residents. This was due to a misunderstanding of notification requirements, as the HIM believed the Ombudsman only needed discharge notifications, contrary to the facility's policy.
A resident with diabetes had a blood sugar level of 409 mg/dL, exceeding the physician's order to notify if levels were above 400 mg/dL. The facility failed to inform the physician, as confirmed by staff interviews and record reviews. The facility's policy requires notifying the physician of significant health changes, which was not followed in this instance.
The facility failed to provide written notification of its bedhold policy to two residents during hospital transfers. A resident was transferred twice without obtaining written confirmation from the resident or their POA, and another resident was transferred without confirmation from their emergency contact. The facility's policy requires notification prior to hospital transfers, but the necessary signatures were not obtained.
The facility failed to accurately code MDS assessments for two residents. One resident's assessments did not reflect prescribed anti-anxiety and opioid medications, despite severe cognitive impairment and relevant diagnoses. Another resident's MDS assessment failed to indicate a serious mental illness, despite confirmation from PASRR Level II. The facility's transition with an MDS coordinator and use of an external company contributed to these errors.
A resident with chronic kidney disease and other conditions experienced significant weight gain without the physician being notified, as required by the physician's orders. The facility failed to consistently monitor the resident's weight, especially after the resident was placed on isolation precautions, leading to a deficiency in care.
The facility failed to ensure safe medication administration for two residents. One resident self-administered inhalers without proper orders or assessment, while another received a medication dose late. Both residents had moderate cognitive impairments, and staff confirmed the deficiencies in medication management.
The facility failed to monitor high-risk medications for three residents, leading to a deficiency in medication management. One resident, cognitively intact, was prescribed hydrocodone-acetaminophen without documented monitoring interventions. Another resident, with severely impaired cognition and on hospice, was prescribed oxycodone without monitoring interventions. A third resident, with multiple diagnoses, was prescribed oxycodone and torsemide without monitoring for side effects. The lack of monitoring for these high-risk medications violated the facility's pain management policy and FDA guidelines.
A resident with severe cognitive impairment was administered medications incorrectly, resulting in a 9.37% medication error rate. The errors included crushing extended-release tablets of carbidopa/levodopa and potassium chloride, which should not have been crushed, and administering an incorrect senna tablet. The LPN acknowledged the errors, citing the resident's swallowing issues, but failed to consult the physician as required.
A resident with rheumatoid arthritis and osteoarthritis experienced a fall resulting in a major injury during a pivot transfer. The facility failed to report the incident to the State Agency in a timely manner and submitted a 5-day investigation report with incorrect details about the fall's timing. The resident confirmed the fall details, which matched the facility's investigation findings.
The facility did not revise care plans for two residents after incidents of falls and an altercation. One resident experienced two falls without subsequent care plan updates, and another resident with severe cognitive impairment was involved in an altercation without care plan revisions to prevent future incidents. The DON confirmed the lack of care plan updates.
Food Items Stored Without Required Date Marking
Penalty
Summary
The facility did not ensure food was stored and prepared in a safe and sanitary manner, with the deficiency centered on time/temperature control foods that were not labeled with open dates and/or use-by dates. During an initial kitchen tour with the Food and Nutrition Services Director (FNSD)-C, surveyors observed multiple dry storage items, coolers, and freezers containing food items that lacked required date markings. The facility’s own policy required refrigerated ready-to-eat time/temperature control for safety foods to be clearly marked with the date or day by which they must be consumed or discarded, and the FNSD-C stated the facility follows the Wisconsin Food Code as its standard of practice. In dry storage, surveyors observed items including salt, baking cocoa, sugar, flour, cracker crumbs, and instant cheese queso mix without use-by dates. In coolers, surveyors observed multiple items without use-by dates, including breaded chicken, baked cookies and cinnamon rolls, chicken thighs, Braunschweiger, breaded chicken patty, sloppy joe, an unlabeled container of yellow material marked open 3/26, cherry cheesecake, pork chops, and pork. In freezers, surveyors observed numerous unlabeled or undated items, including hot dogs, beef, smoth steak, beef tips, sl. beef, beef stroganoff, beef casserole, salisbury steak, lasagna sauce, riblettes, brat patties, BBQ pork, sausage patty, pulled pork, kielbasa, hamloaf, ham, pork in peach sauce, cod, pork, beef, turkey, quiche, squash, fish, soft pot, sweet pot, tavern fish, salmon, fish, turkey, and chx. During interview, FNSD-C stated bulk food items such as flour and sugar did not have use-by dates because they were used up quickly, but then verified the items should contain use-by dates. FNSD-C was unsure of the use-by dates for the dry storage items and stated the cracker crumbs should be thrown out. FNSD-C also did not know the use-by dates for the cheese mix and various items in the cooler and freezer, and confirmed the frozen items should have been labeled with use-by dates. The report states this practice had the potential to affect 74 of 74 residents residing in the facility.
Missing Employee Reference Checks
Penalty
Summary
The facility did not ensure its abuse policy was implemented for 2 of 8 employees reviewed for employee reference checks. The facility's Abuse, Neglect and Exploitation policy, revised 2025, states that potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property and that background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. On 4/1/26, the surveyor reviewed background check information, including BID forms, DOJ letters, governmental findings letters, reference checks, and license information for 8 staff, including CNA-F and CNA-G. CNA-F was hired on 1/26/26 and CNA-G was hired on 2/23/26, but neither employee's background check information included reference checks. During an interview on 4/1/26 at 10:49 AM, the NHA stated that if reference checks were not included, the facility did not have them, and confirmed that reference checks should have been completed for CNA-F and CNA-G.
Failure to Monitor Weight Gain and Notify Physician
Penalty
Summary
The facility did not ensure necessary care and services were provided to monitor weight gain for one resident with end stage renal failure, dependence on renal dialysis, and congestive heart failure. The resident had intact cognition and made his own healthcare decisions. The resident’s physician orders required daily weights and notification if weight increased by 3 pounds in one day or 5 pounds in one week, later changed to weights after dialysis only on Monday, Wednesday, and Friday with the same notification parameters. The resident’s treatment record contained missing weight documentation on multiple dates, and missing documentation was also noted for several shifts related to the resident’s fluid restriction. Survey review of the resident’s recorded weights showed increases that met the physician-notification threshold, including a 6.5-pound increase in one day, a 5.4-pound increase in one day, and a 3.8-pound increase in one day. The registered nurse confirmed that the physician should have been updated regarding these weight gains, and the director of nursing and a registered nurse supervisor also confirmed the physician should have been updated when the resident gained 3 pounds in one day. The registered dietician and registered nurse stated that nurses were responsible for documenting weights and updating the physician with changes.
Missing Dialysis Access Monitoring and Pre-Treatment Documentation
Penalty
Summary
Safe, appropriate dialysis care/services were not fully provided for a resident receiving hemodialysis. The resident had diagnoses including end stage renal failure, dependence on renal dialysis, and congestive heart failure, and had intact cognition with a BIMS score of 15 out of 15. The resident received dialysis on Monday, Wednesday, and Friday. The facility’s dialysis policy required ongoing assessment before dialysis treatments and required the licensed nurse to check the dialysis access site before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. Review of the resident’s TAR showed missing documentation for the dialysis evaluation form before treatment on multiple scheduled dialysis days, as well as missing documentation for AV fistula checks for bruit, thrill, and site condition on several dates. The TAR indicated the pre-treatment dialysis form was not completed on 1/14/26 and 3/9/26, and the AV fistula monitoring orders were not completed on 11/16/25, 2/13/26, and 3/9/26, with one site assessment also missing on 11/16/25. The DON and RNS reviewed the record and confirmed the orders should have been completed and documented, and the RNS could not find progress note documentation matching the missing TAR entries.
Infection Prevention and Control Program Not Maintained for Residents on EBP
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for residents on enhanced barrier precautions (EBP). The deficiency involved three residents with physician orders for EBP related to indwelling catheters and, for two residents, wounds. Survey observations and interviews showed staff did not consistently follow the facility’s EBP requirements during direct care and high-contact activities. For one resident with an indwelling catheter, colostomy, and wounds, the record included an EBP order and care plan directing staff to wear a gown and gloves for all cares. Although an EBP sign and PPE cart were present near the room, a CNA entered the room without a gown to empty the colostomy bag and later entered again with gloves but no gown to empty the catheter bag. During the AM medication pass, an RN administered insulin to the resident without wearing a gown. The CNA and RN both acknowledged they did not wear the required gown, and the RN confirmed insulin administration was direct resident care and should have been done with a gown per the facility policy. A second resident had diagnoses including sepsis due to MRSA, bladder calculus, and obstructive and reflux uropathy, and had an indwelling catheter with an EBP order and care plan. An EBP sign and PPE cart were observed near the room, but an OT entered the room for therapy involving repetitive transfers with a mechanical lift without wearing a gown or gloves. The OT stated PPE was not used because catheter care was not being performed. The resident also stated staff did not wear gowns during catheter care, transfers, bed changes, or other cares, and described having frequent UTIs and needing to assist with catheter care because staff did not do it correctly. A third resident had an indwelling catheter and wound care order with EBP, but the care plan did not indicate the resident was on EBP. Surveyors observed there was no EBP sign posted outside the room on multiple occasions. During catheter care, a CNA emptied the catheter bag without wearing a gown. The DON confirmed a gown was required during direct care for residents with catheters on EBP, confirmed there was no EBP sign posted, and stated staff should know the resident was on EBP because the resident had a catheter. An RNS also stated EBP should be indicated on the care plan for a resident on EBP.
Failure to Report Misappropriation of Narcotic Medications to State Agency
Penalty
Summary
The facility failed to report an allegation of misappropriation of narcotic contingency medications to the State Agency (SA) after discovering missing doses of controlled substances. On 1/11/25, staff identified that several narcotic medications, including fentanyl patches, morphine tablets, oxycodone, Oxycontin, and hydrocodone/APAP, were missing from the contingency box. The incident was reported to local law enforcement, but there was no documentation or evidence that the potential misappropriation was reported to the SA as required by facility policy and regulatory expectations. Interviews with nursing staff revealed that the process for accessing and checking the narcotic contingency box was changed following the incident, with new procedures for verifying tag numbers and conducting visual inspections at shift changes. However, the investigation documentation and administrator interview confirmed that the SA was not notified of the missing medications. The failure to report the suspected misappropriation had the potential to affect any residents who might have needed the diverted medications.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. Eight residents were directly affected by these lapses, with the potential to impact all 74 residents in the facility. The facility's line list for a Norovirus outbreak was found to be inaccurate, with discrepancies in the documentation of residents' symptoms and well dates. For instance, Resident 57 was incorrectly listed as well, despite having symptoms of diarrhea beyond the recorded well date. Similarly, Resident 186 was not included on the line list despite having symptoms, indicating a failure in tracking and managing the outbreak effectively. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for residents requiring such measures. Resident 30, who was on EBP, did not have appropriate PPE available, and staff failed to wear PPE during care activities. This was also observed with Resident 44, where staff did not wear PPE during repositioning, and PPE was not readily available. Furthermore, Resident 38's room lacked PPE, and equipment used for care was not sanitized after use, increasing the risk of infection transmission. The survey also highlighted communication and procedural failures within the facility. Staff were unclear about the necessity of PPE and the status of residents on contact precautions. For example, there was confusion regarding Resident 73's precaution status, with conflicting information between staff and documentation. These deficiencies indicate a lack of proper training and oversight in infection control practices, contributing to the potential spread of infections within the facility.
Call Lights Not Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for five residents who were dependent on staff for mobility and care. During observations, it was noted that the call lights for these residents were not accessible, being either wrapped around nightstand handles, hanging on drawers, or placed across the room. This deficiency was identified through observations and interviews with staff, who acknowledged that the call lights should have been within reach and subsequently repositioned them. The residents involved had various medical conditions, including Alzheimer's disease, palliative care needs, and physical impairments such as hand contractures and spinal issues. These conditions made them reliant on staff assistance and unable to independently access their call lights. The facility's failure to provide accessible call lights was confirmed by the Nursing Home Administrator and Director of Nursing, who acknowledged that residents should have call lights on their person or within reach.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written transfer notices to residents and their representatives, as well as notify the Ombudsman, regarding hospital transfers. Specifically, one resident, identified as R11, was transferred to the hospital on two occasions, but neither the resident nor their Power of Attorney (POA) received a written transfer notice for the transfer on May 1, 2024. Additionally, the facility did not notify the Ombudsman of R11's hospital transfers. The facility also failed to notify the Ombudsman of hospital transfers for five other residents, identified as R33, R21, R30, R59, and R82. Each of these residents experienced hospital transfers on various dates throughout 2024, yet the facility's records did not include these transfers in the reports provided to the Ombudsman. This lack of notification was contrary to the facility's policy, which requires that the Ombudsman be informed of such transfers. Interviews with facility staff and the Ombudsman revealed a misunderstanding regarding the notification requirements. The Health Information Manager (HIM) indicated that hospitalizations were previously included in the monthly report to the Ombudsman, but this practice was discontinued based on a belief that the Ombudsman only wanted notifications of discharges. However, the Ombudsman did not recall instructing the facility to exclude hospital transfer information, suggesting a communication breakdown regarding regulatory requirements.
Failure to Notify Physician of Elevated Blood Sugar Level
Penalty
Summary
The facility failed to notify a physician when a resident's blood sugar level exceeded the parameters set by the physician's order. The resident, identified as R186, had a physician's order to notify the physician if their blood sugar was higher than 400 mg/dL or less than 60 mg/dL. On December 15, 2024, R186's blood sugar level was recorded at 409 mg/dL, but there was no documentation indicating that the physician was notified of this result. The deficiency was confirmed through staff interviews and record reviews. The Registered Nurse (RN) and the Director of Nursing (DON) both acknowledged that the physician should have been notified according to the order. The facility's Notification of Change policy, revised in November 2022, requires consultation with the resident's physician in cases of significant changes in the resident's health status. Despite this policy, the necessary notification was not made, resulting in a failure to comply with the physician's order.
Failure to Provide Bedhold Notification for Hospital Transfers
Penalty
Summary
The facility failed to ensure that two residents, R11 and R33, received written notification of the facility's bedhold policy when they were transferred to the hospital. R11 was transferred to the hospital on two occasions, 2/22/24 and 5/1/24, without obtaining written bedhold confirmation from R11 or R11's Power of Attorney (POA). Similarly, R33 was transferred to the hospital on 8/7/24 without obtaining written bedhold confirmation from R33 or R33's emergency contact. The facility's policy requires that a notice concerning the bedhold policy be given prior to a resident's transfer to a hospital. The surveyor's review of the medical records and interviews with the Nursing Home Administrator (NHA) revealed that the facility did not follow its own policy. The NHA indicated that it was the nurse's responsibility to ask the resident or their representative about the bedhold, and the Social Worker's responsibility to follow up and obtain responses and signatures. However, the facility did not obtain the necessary signatures for R11 and R33's hospitalizations, and the NHA confirmed that signatures should have been obtained. Additionally, the facility did not complete a bedhold for R11's 5/1/24 hospital transfer because R11 did not want a bedhold, and the facility discharged R11 from the record.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. Resident 11, who was prescribed lorazepam and oxycodone, had MDS assessments on three separate occasions that did not reflect the administration of these medications. This oversight occurred despite the resident's documented diagnoses of major depression disorder, altered mental status, and psychophysiologic insomnia, and a Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. Resident 19, diagnosed with schizoaffective disorder and anxiety disorder, was also affected by inaccurate MDS coding. Although the resident's Preadmission Screening and Resident Review (PASRR) Level II confirmed a serious mental illness, the MDS assessment failed to reflect this diagnosis. The Director of Nursing acknowledged the facility's transition period with an MDS coordinator and reliance on an external company for MDS assessments, which contributed to the errors. The Social Worker responsible for completing the relevant MDS section confirmed the coding should have indicated a serious mental illness.
Failure to Monitor Resident's Weight and Notify Physician
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident, identified as R54, by not ensuring consistent weight monitoring and physician notification as per the physician's orders. R54, who was admitted with diagnoses including atrial fibrillation, a history of venous thrombosis and embolism, and stage 3 chronic kidney disease, was supposed to have daily weights for the first three days and then weekly, with the physician being notified of any significant weight changes. However, R54 experienced a significant weight gain over several weeks without the physician being informed, as required by the orders. Despite the physician's order for daily weights due to edema and medication changes, the facility did not consistently obtain R54's weight, particularly after the resident was placed on isolation precautions. The Infection Preventionist confirmed that weights were not taken during this period and acknowledged that the physician was not updated about the inability to obtain the resident's weight. This lack of adherence to the physician's orders and failure to communicate significant weight changes to the physician constituted a deficiency in the care provided to R54.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for two residents, leading to deficiencies in medication administration. One resident, identified as R27, was observed with two inhalers on their bedside table, which they self-administered despite a prior assessment indicating they were unable to do so. The inhalers, Spiriva and Albuterol Sulfate, were brought from home, and there was no physician's order for Spiriva. The facility's policy requires that medications not be kept in resident rooms unless specifically ordered by a physician, and R27 did not have an order to self-administer medication. Interviews with nursing staff confirmed that the inhalers should not have been in the resident's room and that R27 was not assessed as capable of self-administering medication. Another resident, R78, experienced a delay in the administration of their medication. The resident was scheduled to receive a 500 mg tablet of ranolazine at 8:00 AM, but it was administered at 9:07 AM, outside the one-hour window allowed by the facility's policy. Interviews with the LPN and the Director of Nursing confirmed the medication was administered late. Both residents had moderate cognitive impairments and did not have activated healthcare decision-makers, which may have contributed to the oversight in medication management.
Failure to Monitor High-Risk Medications
Penalty
Summary
The facility failed to ensure proper monitoring for high-risk medications for three residents, leading to a deficiency in medication management. Resident 30, who was cognitively intact, was prescribed hydrocodone-acetaminophen for pain but did not have monitoring interventions for opioid use documented in their care plan. Similarly, Resident 69, who had severely impaired cognition and was receiving hospice services, was prescribed oxycodone but lacked monitoring interventions for opioid use in their care plan. The Director of Nursing confirmed that these residents did not have opioid side effect monitoring in their care plans prior to the surveyor's review. Resident 11, who had severely impaired cognition and multiple diagnoses including congestive heart failure and chronic kidney disease, was prescribed both oxycodone and torsemide. The resident's care plan did not include monitoring interventions for either opioid or diuretic use. The Director of Nursing confirmed the absence of side effect monitoring for these medications. The lack of monitoring for adverse reactions or side effects of these high-risk medications constitutes a failure to adhere to the facility's pain management policy and the FDA's guidelines for medications with black box warnings.
Medication Administration Errors Result in 9.37% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 9.37% error rate during medication administration observations. This deficiency affected one resident, identified as R21, who was administered medications incorrectly. Specifically, R21 received two medications in the wrong form and one incorrect medication. The medications involved were carbidopa/levodopa and potassium chloride, both of which were extended-release tablets that should not have been crushed, as per the facility's Medication-Crushing policy and manufacturer guidelines. Additionally, R21 was given a senna tablet that was not ordered by the physician, instead of the prescribed senna plus oral tablet. R21, who had diagnoses including hemiplegia, hemiparesis, and Parkinson's disease, was observed to have severely impaired cognition with a BIMS score of 7 out of 15. The Licensed Practical Nurse (LPN) responsible for administering the medications acknowledged the error, stating that the extended-release medications were crushed due to R21's swallowing issues, but admitted that the physician should have been consulted before doing so. The Assistant Director of Nursing confirmed that extended-release medications should not be crushed, and the LPN verified the administration of the incorrect senna medication.
Delayed Reporting of Resident Fall and Incorrect Investigation Details
Penalty
Summary
The facility failed to report an injury of unknown source involving potential abuse or neglect to the State Agency (SA) in a timely manner for one resident. The incident involved a resident who had a fall resulting in a major injury on 6/30/24. The resident, who had a history of rheumatoid arthritis and osteoarthritis, experienced a fall when their right knee buckled during a pivot transfer from the toilet to a wheelchair, assisted by a Certified Nursing Assistant (CNA). The resident was subsequently diagnosed with a mildly displaced fracture of the right distal femoral diaphysis. The facility's 5-day investigation report, which was due on 7/8/24, was submitted late on 7/9/24 and contained incorrect information regarding the time of the fall. The facility's policy on Abuse, Neglect, and Exploitation requires immediate notification to the appropriate regulatory agencies and submission of investigation results within 5 working days. However, the Nursing Home Administrator confirmed that the time of the fall was incorrectly listed in the investigation report, and the submission to the SA was delayed. The resident, who had little to no cognitive impairment, confirmed the details of the fall during an interview, which were consistent with the facility's investigation findings.
Failure to Revise Care Plans After Falls and Altercations
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for two residents. One resident, who had diagnoses including rheumatoid arthritis and osteoarthritis, experienced two falls on separate occasions. The first fall occurred while being transferred with a sit-to-stand mechanical lift when the resident's feet slipped off the lift platform. The second fall happened when the resident slid off a recliner after being transferred, with their feet getting tangled in wheelchair pedals. Despite these incidents, the facility did not revise the resident's care plan to prevent future falls. Another resident, with severe cognitive impairment and diagnoses including chronic kidney disease and congestive heart failure, was involved in an altercation where they slapped another resident and told them to shut up. Following this incident, the facility did not update the resident's care plan or implement interventions to prevent further inappropriate interactions with other residents. The Director of Nursing confirmed that care plans were not revised after these incidents, which is expected to help prevent future occurrences.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 153 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fond Du Lac
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harbor Haven Health & Rehabilitation | 0.3 mi | ★★★★★ | 0 | 0 |
| Avina On Division | 0.4 mi | ★★★★★ | 11 | 1 |
| Avina Of Fond Du Lac | 0.7 mi | ★★★★★ | 6 | 0 |
| Edenbrook Of Fond Du Lac | 0.8 mi | ★★★★★ | 0 | 0 |
| Fond Du Lac Lutheran Home | 0.9 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St Francis Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.