01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-04-09 | 17 | 2026-04-09 | 5 |
| Cycle 2 | 2024-11-14 | 25 | 2024-11-14 | 9 |
| Cycle 3 | 2023-10-05 | 8 | 2023-10-05 | 3 |
CMS CCN 5255282026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Franciscan Woods
19525 W North Ave · Brookfield, WI 53045 · Waukesha County
Certified beds110CMS provider file
Recent citation rows67current CMS citation release
Penalty rows3current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
67 rows in the current release
5 rows carry G–L scope/severity codes; 0 carry J–L. 13 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-09 · HEALTHF0552Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0628Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0676Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure 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.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure 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.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0849Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0881Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0887Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Educate 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.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · FIREK0321Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2026-05-302026-04-09 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · FIREK0364Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install properly constructed windows in hallway walls or doors.
Correction field: Deficient, Provider has date of correction · 2026-05-302026-04-09 · FIREK0372Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2026-05-302026-04-09 · FIREK0916Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Correction field: Deficient, Provider has date of correction · 2026-05-082025-12-22 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-02-03 · complaint2025-12-22 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2026-02-03 · complaint2025-12-03 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-12-19 · complaint2025-05-06 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-06-02 · complaint2025-05-06 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-06-02 · complaint03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-02-11 | Fine | $120,905 | 0 |
| 2025-02-11 | Payment Denial | $0 | 97 |
| 2024-11-14 | Payment Denial | $0 | 31 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- ASCENSION HEALTH SENIOR CAREOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 07/01/2014
- MUSGRAVE, LISAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- SHADBOLT, ERINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- SMOOT, KENNETHIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- SIDHU, SARFRAZIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2018
- ST LOUIS, STEVENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/23/2025
- ASCENSION HEALTH SENIOR CAREOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/01/2015
- FAST PACE MEDICAL STAFFING INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 10/07/2022
- FAVORITE HEALTHCARE STAFFING LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 10/14/2022
- HEALTH DIMENSIONS CONSULTING INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/29/2025
- HOUSE HEALTHCARE SOLUTIONS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 06/10/2025
- MEDICAL SOLUTIONS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 06/14/2017
- MEDICAL STAFFING SOLUTIONS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 10/06/2020
- MICHAEL PORTEROrganization · ADP OF THE SNFNOT APPLICABLE · since 05/09/2021
- NURSING CENTERS, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 06/08/2020
- PERSONNEL SPECIALISTS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/10/2025
- PRN HEALTH SERVICES, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 08/19/2022
- PROLINK HEALTHCARE LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/26/2023
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.39per resident day
RN hours0.95per resident day
Weekend nurse hours3.67per resident day
Staff turnover76.0%CMS reported field