Acute Care Hospitals · Voluntary non-profit - Private
Ssm Health St Agnes Hospital-Fond Du Lac
- 430 E Division St, Fond Du Lac, WI 54935
- (920) 929-2300
- Acute Care Hospitals
- Emergency services available 24/7
At a glance
Ssm Health St Agnes Hospital-Fond Du Lac carries a 4-star CMS overall rating — above the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 and worse on 0.
Healthcare-Associated Infections
lower is better · 36 measures reported
Rates of infections patients can acquire while receiving care, such as central-line and catheter-associated infections, MRSA, and C. difficile.
| Measure | Score | Compared to national |
|---|---|---|
| Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit | 0.024 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit | 2.398 | Same as national |
| Central Line Associated Bloodstream Infection: Number of Device Days | 2569 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases | 2.057 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases | 1 | Same as national |
| Central Line Associated Bloodstream Infection (ICU + select Wards) | 0.486 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit | — | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit | 1.053 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days | 3586 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases | 2.845 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases | 0 | Same as national |
| Catheter Associated Urinary Tract Infections (ICU + select Wards) | 0.000 | Same as national |
| SSI - Colon Surgery: Lower Confidence Limit | — | Same as national |
| SSI - Colon Surgery: Upper Confidence Limit | 2.183 | Same as national |
| SSI - Colon Surgery: Number of Procedures | 53 | Same as national |
| SSI - Colon Surgery: Predicted Cases | 1.372 | Same as national |
| SSI - Colon Surgery: Observed Cases | 0 | Same as national |
| SSI - Colon Surgery | 0.000 | Same as national |
| SSI - Abdominal Hysterectomy: Lower Confidence Limit | — | Not available |
| SSI - Abdominal Hysterectomy: Upper Confidence Limit | — | Not available |
| SSI - Abdominal Hysterectomy: Number of Procedures | 18 | Not available |
| SSI - Abdominal Hysterectomy: Predicted Cases | 0.138 | Not available |
| SSI - Abdominal Hysterectomy: Observed Cases | 0 | Not available |
| SSI - Abdominal Hysterectomy | — | Not available |
| MRSA Bacteremia: Lower Confidence Limit | — | Same as national |
| MRSA Bacteremia: Upper Confidence Limit | 1.876 | Same as national |
| MRSA Bacteremia: Patient Days | 33594 | Same as national |
| MRSA Bacteremia: Predicted Cases | 1.597 | Same as national |
| MRSA Bacteremia: Observed Cases | 0 | Same as national |
| MRSA Bacteremia | 0.000 | Same as national |
| Clostridium Difficile (C.Diff): Lower Confidence Limit | 0.076 | Better than national |
| Clostridium Difficile (C.Diff): Upper Confidence Limit | 0.578 | Better than national |
| Clostridium Difficile (C.Diff): Patient Days | 32023 | Better than national |
| Clostridium Difficile (C.Diff): Predicted Cases | 16.703 | Better than national |
| Clostridium Difficile (C.Diff): Observed Cases | 4 | Better than national |
| Clostridium Difficile (C.Diff) | 0.239 | Better than national |
Complications & Deaths
lower is better · 20 measures reported
Rates of serious complications (like hip/knee replacement problems or accidental cuts during surgery) and 30-day mortality rates for common conditions.
| Measure | Score | Compared to national | Sample |
|---|---|---|---|
| Rate of complications for hip/knee replacement patients | — | Not available | — |
| Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate | 3.7 | Same as national | 603 |
| Death rate for heart attack patients | 11.6 | Same as national | 107 |
| Death rate for CABG surgery patients | 2.7 | Same as national | 36 |
| Death rate for COPD patients | 11.2 | Same as national | 42 |
| Death rate for heart failure patients | 13.6 | Same as national | 195 |
| Death rate for pneumonia patients | 17.8 | Same as national | 177 |
| Death rate for stroke patients | 13.7 | Same as national | 74 |
| Pressure ulcer rate | 1.42 | Same as national | 1974 |
| Death rate among surgical inpatients with serious treatable complications | — | Not available | — |
| Iatrogenic pneumothorax rate | 0.24 | Same as national | 2326 |
| In-hospital fall-associated fracture rate | 0.29 | Same as national | 2402 |
| Postoperative hemorrhage or hematoma rate | 2.62 | Same as national | 474 |
| Postoperative acute kidney injury requiring dialysis rate | 1.48 | Same as national | 170 |
| Postoperative respiratory failure rate | 5.14 | Same as national | 186 |
| Perioperative pulmonary embolism or deep vein thrombosis rate | 2.89 | Same as national | 521 |
| Postoperative sepsis rate | 4.48 | Same as national | 167 |
| Postoperative wound dehiscence rate | 1.71 | Same as national | 86 |
| Abdominopelvic accidental puncture or laceration rate | 0.97 | Same as national | 401 |
| CMS Medicare PSI 90: Patient safety and adverse events composite | 1.06 | Same as national | — |
Unplanned Hospital Visits & Readmissions
lower is better · 14 measures reported
How often patients return to the hospital unexpectedly within 30 days of discharge — a marker of care quality and discharge planning.
| Measure | Score | Compared to national | Sample |
|---|---|---|---|
| Hospital return days for heart attack patients | -29.3 | Not available | 110 |
| Hospital return days for heart failure patients | -33.6 | Not available | 208 |
| Hospital return days for pneumonia patients | 8.3 | Not available | 173 |
| Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) | 15 | Same as national | 974 |
| Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) | 12.3 | Same as national | 947 |
| Rate of inpatient admissions for patients receiving outpatient chemotherapy | 10.3 | Same as national | 147 |
| Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy | 4.6 | Same as national | 147 |
| Ratio of unplanned hospital visits after hospital outpatient surgery | 1 | Same as national | 291 |
| Acute Myocardial Infarction (AMI) 30-Day Readmission Rate | 12.9 | Same as national | 110 |
| Rate of readmission for CABG | 11.2 | Same as national | 35 |
| Rate of readmission for chronic obstructive pulmonary disease (COPD) patients | 18.9 | Same as national | 44 |
| Heart failure (HF) 30-Day Readmission Rate | 18.3 | Same as national | 208 |
| Rate of readmission after hip/knee replacement | — | Not available | — |
| Pneumonia (PN) 30-Day Readmission Rate | 16.2 | Same as national | 173 |
Patient Experience (HCAHPS)
higher is better · 9 measures reported
What patients say about their hospital stay — communication with nurses and doctors, responsiveness, cleanliness, pain management, and whether they would recommend the hospital.
| Measure | Score | Sample |
|---|---|---|
| Nurse communication - star rating | 4 | 547 |
| Doctor communication - star rating | 3 | 547 |
| Communication about medicines - star rating | 3 | 547 |
| Discharge information - star rating | 5 | 547 |
| Cleanliness - star rating | 4 | 547 |
| Quietness - star rating | 4 | 547 |
| Overall hospital rating - star rating | 4 | 547 |
| Recommend hospital - star rating | 2 | 547 |
| Summary star rating | 4 | 547 |
Timely & Effective Care
higher is better (unless a wait time) · 30 measures reported
How consistently hospitals follow recommended care processes — for example, giving heart-attack patients aspirin on arrival, or the average time spent in the emergency department.
| Measure | Score | Sample |
|---|---|---|
| Emergency department volume | medium | — |
| Global Malnutrition Composite Score | — | — |
| Global Malnutrition Composite Score: Malnutrition Diagnosis Documented | — | — |
| Global Malnutrition Composite Score: Malnutrition Risk Screening | — | — |
| Global Malnutrition Composite Score: Nutrition Assessment | — | — |
| Global Malnutrition Composite Score: Nutritional Care Plan | — | — |
| Hospital Harm - Severe Hyperglycemia | — | — |
| Hospital Harm - Severe Hypoglycemia | 1 | 1418 |
| Hospital Harm - Opioid Related Adverse Events | — | — |
| Healthcare workers given influenza vaccination | 84 | 1683 |
| Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better | 161 | 401 |
| Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better | 157 | 373 |
| Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better | 231 | 20 |
| Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better | — | — |
| Left before being seen | 1 | 29751 |
| Head CT results | 84 | 19 |
| Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients | 99 | 84 |
| Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery | — | — |
| ST-Segment Elevation Myocardial Infarction (STEMI) | — | — |
| Safe Use of Opioids - Concurrent Prescribing | 13 | 1219 |
| Appropriate care for severe sepsis and septic shock | 69 | 91 |
| Septic Shock 3-Hour Bundle | 67 | 27 |
| Septic Shock 6-Hour Bundle | 50 | 14 |
| Severe Sepsis 3-Hour Bundle | 90 | 92 |
| Severe Sepsis 6-Hour Bundle | 95 | 58 |
| Discharged on Antithrombotic Therapy | 100 | 70 |
| Anticoagulation Therapy for Atrial Fibrillation/Flutter | — | — |
| Antithrombotic Therapy by End of Hospital Day 2 | 94 | 81 |
| Venous Thromboembolism Prophylaxis | — | — |
| Intensive Care Unit Venous Thromboembolism Prophylaxis | — | — |
Maternal Health
lower is better · 4 measures reported
Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.
| Measure | Score | Sample |
|---|---|---|
| Cesarean Birth | — | — |
| Risk Adjusted Severe Obstetric Complications (All) | — | — |
| Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases) | — | — |
| Maternal Morbidity Structural Measure | Yes | — |
Frequently asked questions
- How is Ssm Health St Agnes Hospital-Fond Du Lac rated?
- Ssm Health St Agnes Hospital-Fond Du Lac has a 4 out of 5 CMS overall star rating as of the latest CMS release.
- Does Ssm Health St Agnes Hospital-Fond Du Lac have emergency services?
- Yes. Ssm Health St Agnes Hospital-Fond Du Lac operates a 24/7 emergency department.
- Where is Ssm Health St Agnes Hospital-Fond Du Lac located?
- Ssm Health St Agnes Hospital-Fond Du Lac is located at 430 E Division St, Fond Du Lac, WI 54935.
- What type of hospital is Ssm Health St Agnes Hospital-Fond Du Lac?
- Ssm Health St Agnes Hospital-Fond Du Lac is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).
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Data as of 2026-06-14. Source: CMS Provider Data Catalog. This is public data provided for informational purposes only and is not medical advice. See our methodology and editorial policy.