ST FRANCIS HOME

Nursing Home Inspector

33 EVERETT ST
FOND DU LAC, WI 54935
Fond Du Lac County
Phone: 920-923-7980
Provider Number: 525595
Last Inspection: 09/14/2017

About the Nursing Home

Number of Beds: 107
Number of Residents: 90
Beds Available: 17
Percent Occupancy: 84%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: Non profit - Church related
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

3

Facility
11

County
19

WI
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

3

2017
0

2016
3

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

9/14/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 10/14/2017
 

4/15/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 5/5/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg WI State Avg
Number of Residents 90 54.78 64.95
Registered Nurses 1.07 0.87 1.00
Licensed Practical / Vocational Nurses 0.38 0.45 0.56
Certified Nursing Assistants 3.08 2.16 2.54
Total Staff Hours 4.53 3.49 4.11

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% WI State Avg%
of high risk long-stay residents with pressure ulcers 3 5 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 99 98 98
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 97 96
of long-stay residents experiencing one or more falls with major injury 2 4 3
of long-stay residents who have depressive symptoms 7 4 5
of long-stay residents who lose too much weight 4 8 7
of long-stay residents who received an antianxiety or hypnotic medication 7 17 18
of long-stay residents who received an antipsychotic medication 4 12 12
of long-stay residents who self-report moderate to severe pain 3 7 7
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 14 20 18
of long-stay residents whose need for help with daily activities has increased 9 12 13
of long-stay residents with a catheter inserted and left in their bladder 2 2 2
of long-stay residents with a urinary tract infection 4 5 3
of low risk long-stay residents who lose control of their bowels or bladder 69 54 46
of short-stay residents assessed and appropriately given the pneumococcal vaccine 100 97 90
of short-stay residents who had an outpatient emergency department visit 17 14 12
of short-stay residents who made improvements in function 77 74 74
of short-stay residents who newly received an antipsychotic medication 0 1 1
of short-stay residents who self-report moderate to severe pain 22 20 18
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 92 89 86
of short-stay residents who were rehospitalized after a nursing home admission 11 18 18
of short-stay residents who were successfully discharged to the community 77 68 61
of short-stay residents with pressure ulcers that are new or worsened 0 0 0