St Francis Home

Inspection findings

1. Apr 1, 2026 Health · 12 findings
   • Not serious Scope/severity E

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Apr 24, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Apr 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected Apr 10, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 10, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0132 Construction Deficiencies

     Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

     Corrected Apr 20, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0271 Egress Deficiencies

     Have exits that are accessible at all times.

     Corrected May 1, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 20, 2026 · CMS fire safety

   • Not serious Scope/severity C

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Apr 20, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0753 Miscellaneous Deficiencies

     Have restrictions on the use of highly flammable decorations.

     Corrected Apr 20, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0914 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.

     Corrected Apr 30, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Apr 20, 2026 · CMS fire safety

2. Apr 21, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected May 16, 2025 · CMS health inspection

3. Dec 18, 2024 Health · 17 findings
   • Not serious Scope/severity E

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0580 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.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0623 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.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0625 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.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Jan 18, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 31, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Jan 31, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     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.

     Corrected Jan 31, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0281 Egress Deficiencies

     Install proper backup exit lighting.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0311 Smoke Deficiencies

     Have an enclosure around a vertical opening shaft.

     Corrected Jan 18, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0361 Smoke Deficiencies

     Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

     Corrected Jan 18, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Jan 18, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jan 31, 2025 · CMS fire safety

4. Jul 29, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Aug 29, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Aug 29, 2024 · CMS health inspection

5. Jan 11, 2024 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Feb 11, 2024 · CMS health inspection

6. Nov 9, 2023 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Dec 9, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Dec 9, 2023 · CMS health inspection

7. Sep 13, 2023 Fire Safety · 12 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Sep 28, 2023 · CMS fire safety

   • Not serious Scope/severity D

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected Oct 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Oct 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Oct 13, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Oct 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Oct 13, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0131 Construction Deficiencies

     Meet requirements for sections of health care facilities separated by fire resistive construction.

     Corrected Feb 27, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     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.

     Corrected Oct 20, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected Sep 15, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Sep 15, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0541 Services Deficiencies

     Install properly constructed and protected linen or trash chutes.

     Corrected Sep 15, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0914 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.

     Corrected Nov 8, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• ANDERSON, SUE — operational/managerial control, NOT APPLICABLE, since 01/01/2024
• ANDERSON, SUE — managing control - governing body, NOT APPLICABLE, since 02/28/2022
• BASS, PAIGE — managing control - governing body, NOT APPLICABLE, since 01/01/2025
• BEARDMORE, DANIEL — managing control - governing body, NOT APPLICABLE, since 11/12/2024
• BELL, JUDITH — managing control - governing body, NOT APPLICABLE, since 01/01/2023
• BRISCOE, DAVID — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• BRISCOE, DAVID — adp of the snf, NOT APPLICABLE, since 04/01/2022
• BRISCOE, PATRICIA — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• BRISCOE, PATRICIA — adp of the snf, NOT APPLICABLE, since 04/01/2022
• BROWN, MARY — managing control - governing body, NOT APPLICABLE, since 01/04/2018
• BURNETT, JANICE — managing control - governing body, NOT APPLICABLE, since 01/01/2022
• CORCORAN, RICK — managing control - governing body, NOT APPLICABLE, since 10/01/2017
• DEVLIN, MARIE — managing control - governing body, NOT APPLICABLE, since 06/01/2018
• DOLAN, PETER — managing control - governing body, NOT APPLICABLE, since 01/01/2024
• EMMER, RHEA — managing control - governing body, NOT APPLICABLE, since 02/28/2022
• GLOEDE, DENISE — corporate officer, NOT APPLICABLE, since 11/01/2024
• GLOEDE, DENISE — managing control - governing body, NOT APPLICABLE, since 11/01/2024
• GLOEDE, DENISE — operational/managerial control, NOT APPLICABLE, since 01/01/2024
• HARDT, JOHN — managing control - governing body, NOT APPLICABLE, since 01/01/2022
• HARTENBACH, DAVID — managing control - governing body, NOT APPLICABLE, since 01/01/2025
• HENNESSEY, ERIN — adp of the snf, NOT APPLICABLE, since 04/01/2022
• HENNESSEY, ERIN — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• HER, PENG — managing control - governing body, NOT APPLICABLE, since 12/13/2023
• HOLZMAN, MARK — managing control - governing body, NOT APPLICABLE, since 12/13/2023
• IMHOLZ, DONALD — managing control - governing body, NOT APPLICABLE, since 06/01/2018
• KAISER, LAURA — managing control - governing body, NOT APPLICABLE, since 05/01/2017
• KARSTEN, JOAN — managing control - governing body, NOT APPLICABLE, since 05/11/2021
• KINDLE, CAROLYN — managing control - governing body, NOT APPLICABLE, since 01/01/2022
• KRUEGER, KARI — operational/managerial control, NOT APPLICABLE, since 09/01/2022
• KRUEGER, KARI — corporate officer, NOT APPLICABLE, since 06/26/2025
• LEITZEN FYE, PATTI — managing control - governing body, NOT APPLICABLE, since 01/01/2024
• MASKEL, JENNIFER — managing control - governing body, NOT APPLICABLE, since 01/01/2019
• MATZKE, WAYNE — managing control - governing body, NOT APPLICABLE, since 05/11/2021
• NAIRN, THOMAS — managing control - governing body, NOT APPLICABLE, since 01/01/2024
• OTTE, OLIVIA — managing control - governing body, NOT APPLICABLE, since 11/12/2024
• PANDL, MARY — managing control - governing body, NOT APPLICABLE, since 01/01/2024
• POGODZINSKI, MATTHEW — managing control - governing body, NOT APPLICABLE, since 11/29/2022
• QUEDNOW, DAWN — adp of the snf, NOT APPLICABLE, since 05/12/2025
• QUEDNOW, DAWN — operational/managerial control, NOT APPLICABLE, since 11/01/2024
• RADINA, VICTOR — operational/managerial control, NOT APPLICABLE, since 06/01/2025
• RADINA, VICTOR — corporate officer, NOT APPLICABLE, since 06/01/2025
• RADINA, VICTOR — managing control - governing body, NOT APPLICABLE, since 06/01/2025
• ROGOTZKE, AMBER — adp of the snf, NOT APPLICABLE, since 04/01/2022
• ROGOTZKE, AMBER — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• ROSS, SAMUEL — managing control - governing body, NOT APPLICABLE, since 09/16/2020
• ROZIER, MICHAEL — managing control - governing body, NOT APPLICABLE, since 01/01/2018
• SHVETZOFF, SERGEI — adp of the snf, NOT APPLICABLE, since 04/01/2022
• SHVETZOFF, SERGEI — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• SHVETZOFF, TAMI — adp of the snf, NOT APPLICABLE, since 04/01/2022
• SHVETZOFF, TAMI — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• SMITH, KEVIN — corporate director, NOT APPLICABLE, since 01/01/2024
• SMITH, KEVIN — managing control - governing body, NOT APPLICABLE, since 01/01/2024
• SMITH, KEVIN — corporate officer, NOT APPLICABLE, since 01/01/2024
• SPARKMAN, WESLEY — managing control - governing body, NOT APPLICABLE, since 12/01/2015
• VALDEZ, JOSEPH — managing control - governing body, NOT APPLICABLE, since 08/01/2022
• VALDIVIA, TOMAS — managing control - governing body, NOT APPLICABLE, since 01/01/2023
• WALKUP, JAMES — managing control - governing body, NOT APPLICABLE, since 01/01/2025
• WALKUP, JAMES — corporate director, NOT APPLICABLE, since 01/01/2025
• WALKUP, JAMES — corporate officer, NOT APPLICABLE, since 01/01/2025
• WEBER, LISA — operational/managerial control, NOT APPLICABLE, since 11/01/2024
• WEBER, LISA — adp of the snf, NOT APPLICABLE, since 04/16/2025
• WHALEN, JAMES — managing control - governing body, NOT APPLICABLE, since 10/01/2017
• WILSON, AMY — managing control - governing body, NOT APPLICABLE, since 06/01/2025
• WILSON, AMY — operational/managerial control, NOT APPLICABLE, since 06/01/2025
• WILSON, AMY — corporate officer, NOT APPLICABLE, since 06/01/2025
• AGNESIAN HEALTHCARE INC — operational/managerial control, NOT APPLICABLE, since 06/01/1978
• HEALTH DIMENSIONS CONSULTING INC — adp of the snf, NOT APPLICABLE, since 05/21/2025
• HEALTH DIMENSIONS CONSULTING INC — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• SSM HEALTH CARE CORPORATION — adp of the snf, NOT APPLICABLE, since 05/22/2025
• SSM HEALTH CARE CORPORATION — operational/managerial control, NOT APPLICABLE, since 01/01/2018
• SSM HEALTH CARE OF WISCONSIN INC — operational/managerial control, NOT APPLICABLE, since 01/01/2018
• SSM HEALTH CARE OF WISCONSIN INC — adp of the snf, NOT APPLICABLE, since 05/21/2025