Nursing homeActive
Franciscan Woods
19525 W North Ave, Brookfield, WI 530452627851114110 certified beds · 55 residentsNon profit - CorporationMedicare and Medicaid
Surveys on file
11
since 2023
Deficiencies
50
● 2● 43● 5
Penalties · 3 yrs
$120,905
1 fine · 2 actions
Last survey
2026-04-09
Standard
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 1
Staffing 4
Quality 2
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Wisconsin Division of Quality Assurance · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-04-09 | Standard | 0140 | CMS-2567 (Care Compare) | — |
| 2025-12-22 | Complaint | 011 | CMS-2567 (Care Compare) | — |
| 2025-12-03 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-05-06 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2025-03-20 | Complaint | 062 | CMS-2567 (Care Compare) | — |
| 2025-02-11 | Complaint | 011 | CMS-2567 (Care Compare) | — |
| 2025-01-14 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-12-23 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-11-14 | Standard | 181 | CMS-2567 (Care Compare) | — |
| 2024-04-05 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-10-05 | Standard | 160 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Wisconsin Division of Quality Assurance publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F552Ensure that residents are fully informed and understand their health status, care and treatments.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-08Record 525528-20260409-F552
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-08Record 525528-20260409-F628
F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-08Record 525528-20260409-F676
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-08Record 525528-20260409-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-08Record 525528-20260409-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-08Record 525528-20260409-F689
F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-08Record 525528-20260409-F693
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-08Record 525528-20260409-F755
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-08Record 525528-20260409-F761
F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-08Record 525528-20260409-F849
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-05-08Record 525528-20260409-F880
F881Implement a program that monitors antibiotic use.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-05-08Record 525528-20260409-F881
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-08Record 525528-20260409-F883
F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-08Record 525528-20260409-F887
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2026-02-03Record 525528-20251222-F686
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-03Record 525528-20251222-F759
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-19Record 525528-20251203-F600
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-02Record 525528-20250506-F689
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-02Record 525528-20250506-F755
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-02Record 525528-20250506-F757
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-06-18Record 525528-20250320-F686
F692Provide enough food/fluids to maintain a resident's health.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-04-23Record 525528-20250320-F692
F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-23Record 525528-20250320-F585
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-04-23Record 525528-20250320-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-23Record 525528-20250320-F609
F610Respond appropriately to all alleged violations.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-04-23Record 525528-20250320-F610
F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-23Record 525528-20250320-F700
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-06-02Record 525528-20250320-F880
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-06-18Record 525528-20250211-F686
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-12Record 525528-20250211-F684
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-14Record 525528-20250114-F757
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-23Record 525528-20241223-F755
F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-12-10Record 525528-20241114-F693
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-10Record 525528-20241114-F580
F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-10Record 525528-20241114-F585
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-10Record 525528-20241114-F623
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-10Record 525528-20241114-F677
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-12-10Record 525528-20241114-F725
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-10Record 525528-20241114-F758
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-10Record 525528-20241114-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-10Record 525528-20241114-F880
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2024-12-10Record 525528-20241114-F732
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-05-05Record 525528-20240405-F842
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-04Record 525528-20231005-F609
F610Respond appropriately to all alleged violations.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-04Record 525528-20231005-F610
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-04Record 525528-20231005-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-04Record 525528-20231005-F686
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-04Record 525528-20231005-F755
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-04Record 525528-20231005-F758
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity CPaperwork
Abuse & neglect
Widespread; potential for minimal harm.Corrected 2023-11-04Record 525528-20231005-F607
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2025-02-11 | Civil money penalty | $120,905 | CMS · Penalties |
| 2025-02-11 | Denial of payment for new admissions Payment denial for 97 days, from 2025-03-13 | — | CMS · Penalties |
| 2024-11-14 | Denial of payment for new admissions Payment denial for 31 days, from 2024-12-14 | — | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.95
Facility
Wisconsin
National
Wisconsin 0.99 · National 0.69
Total nurse hours per resident day4.39
Facility
Wisconsin
National
Wisconsin 4.21 · National 3.86
Weekend total nurse hours3.67
Facility
Wisconsin
National
Wisconsin 3.77 · National 3.42
Total nursing staff turnover76%
Facility
Wisconsin
National
Wisconsin 47% · National 46%
Registered nurse turnover27%
Facility
Wisconsin
National
Wisconsin 40% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Wisconsin | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 7.7% | 5.0% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 1.0% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 13.4% | 15.8% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 1.5% | 2.7% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 20.9% | 16.1% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 7.9% | 5.1% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 19.4% | 16.9% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Ascension Health Senior Care Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Sidhu, Sarfraz Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| St Louis, Steven Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Ascension Health Senior Care Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Fast Pace Medical Staffing Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Favorite Healthcare Staffing LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Health Dimensions Consulting Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| House Healthcare Solutions LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Medical Solutions LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Medical Staffing Solutions LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Michael Porter Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Musgrave, Lisa Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Musgrave, Lisa Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Nursing Centers, Inc. Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Personnel Specialists LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Prn Health Services, Inc. Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Prolink Healthcare LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Shadbolt, Erin Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Shadbolt, Erin Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Sidhu, Sarfraz Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Smoot, Kenneth Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Smoot, Kenneth Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| St Louis, Steven Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Staff One, Ltd. Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Ascension Living — 12 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Wisconsin.
No county cost figures on file for Waukesha.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Complete Care at Care Age Brookfield | 0.7 mi | 2025-12-03 | 0213 |
| Aria of Brookfield Brookfield | 1.9 mi | 2026-02-05 | 29110 |
| Aria of Waukesha Waukesha | 4.0 mi | 2026-02-16 | 0172 |
| Congregational Home, Inc. Brookfield | 3.7 mi | 2025-07-31 | 0131 |
| Menomonee Falls Health Services Menomonee Falls | 6.2 mi | 2025-12-03 | 0405 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |