CareSentinel

Federal Nursing-Home Survey Record

Franciscan Woods

CCN 525528 · 19525 W NORTH AVE, BROOKFIELD, WI, 53045 · Operated within the ASCENSION LIVING chain

Does Franciscan Woods have a federal violation or abuse history?

According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), Franciscan Woods (CCN 525528), in BROOKFIELD, WI, has federal inspection findings on its record. In its current inspection cycle, CMS cited the facility for 16 deficiencies; the most serious carries scope/severity G on CMS's A–L scale, a level CMS classifies as actual harm. The most recent federal survey on file is dated 2024-11-14. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $120,214 in civil money penalties on file against the facility. This page restates the federal record as published by CMS and draws no conclusion of its own. Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.

The Federal Record

At its most recent federal inspection, CMS cited this facility for 2 actual-harm deficiencies.

Below is this facility's federal survey record as on file with federal regulators (CMS). Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.

Scope & Severity — current cycle

ANo Harm
BNo Harm
CNo Harm
DPotential
EPotential
FPotential
GActual Harm
HActual Harm
IActual Harm
JImm. Jeopardy
KImm. Jeopardy
LImm. Jeopardy

CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations, as on file with federal regulators (CMS).

Civil money penalties on file

$120,214

CMS has $120,214 in civil money penalties on file against this facility. CMS also records 128 day(s) of payment denial.

Overall CMS star rating: this facility vs the CMS-published state average

This facility: 2  ·  CMS state average: 3.0

Side-by-side with the CMS-published Overall CMS star rating for this state. This is the government's own published state average — not a CareSentinel-computed figure or delta.

Deficiency timeline — full federal history

2025-12-22
CURRENT CYCLE
F686S/S G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

2025-12-22
CURRENT CYCLE
F759S/S D

Ensure medication error rates are not 5 percent or greater.

2025-12-03
CURRENT CYCLE
F600S/S D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

2025-05-06
CURRENT CYCLE
F755S/S D

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

2025-05-06
CURRENT CYCLE
F757S/S D

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

2025-05-06
CURRENT CYCLE
F689S/S D

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

2025-03-20
HISTORICAL
F692S/S G

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

2025-03-20
HISTORICAL
F686S/S G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

2025-03-20
HISTORICAL
F880S/S F

Provide and implement an infection prevention and control program.

2025-03-20
HISTORICAL
F607S/S E

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

2025-03-20
HISTORICAL
F610S/S E

Respond appropriately to all alleged violations.

2025-03-20
HISTORICAL
F609S/S D

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

2025-03-20
HISTORICAL
F700S/S D

Try 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.

2025-03-20
HISTORICAL
F585S/S D

Honor 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.

2025-02-11
HISTORICAL
F686S/S G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

2025-02-11
HISTORICAL
F684S/S D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

2025-01-14
HISTORICAL
F757S/S D

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

2024-12-23
HISTORICAL
F755S/S D

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

2024-11-14
CURRENT CYCLE
F693S/S G

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.

2024-11-14
CURRENT CYCLE
F725S/S F

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

2024-11-14
CURRENT CYCLE
F880S/S E

Provide and implement an infection prevention and control program.

2024-11-14
CURRENT CYCLE
F812S/S E

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

2024-11-14
CURRENT CYCLE
F585S/S D

Honor 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.

2024-11-14
CURRENT CYCLE
F623S/S D

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

2024-11-14
CURRENT CYCLE
F677S/S D

Provide care and assistance to perform activities of daily living for any resident who is unable.

2024-11-14
CURRENT CYCLE
F758S/S D

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.

2024-11-14
CURRENT CYCLE
F580S/S D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

2024-11-14
CURRENT CYCLE
F732S/S C

Post nurse staffing information every day.

2024-04-05
HISTORICAL
F842S/S E

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

2023-10-05
HISTORICAL
F610S/S E

Respond appropriately to all alleged violations.

2023-10-05
HISTORICAL
F609S/S E

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

2023-10-05
HISTORICAL
F684S/S D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

2023-10-05
HISTORICAL
F686S/S D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

2023-10-05
HISTORICAL
F755S/S D

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

2023-10-05
HISTORICAL
F758S/S D

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.

2023-10-05
HISTORICAL
F607S/S C

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

2022-07-18
HISTORICAL
F684S/S G

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

2022-07-18
HISTORICAL
F607S/S E

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

2022-07-18
HISTORICAL
F756S/S D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

2022-07-18
HISTORICAL
F623S/S D

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

2022-07-18
HISTORICAL
F758S/S D

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.

2022-07-18
HISTORICAL
F625S/S D

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.

2022-07-18
HISTORICAL
F660S/S D

Plan the resident's discharge to meet the resident's goals and needs.

2022-07-18
HISTORICAL
F812S/S D

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

2022-07-18
HISTORICAL
F661S/S D

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

2022-07-18
HISTORICAL
F880S/S D

Provide and implement an infection prevention and control program.

2022-07-18
HISTORICAL
F610S/S D

Respond appropriately to all alleged violations.

2022-07-18
HISTORICAL
F582S/S D

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

2022-07-18
HISTORICAL
F740S/S D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

2022-07-18
HISTORICAL
F695S/S D

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

2022-07-18
HISTORICAL
F609S/S D

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

Each citation below is a federal survey finding, dated and labeled with its CMS deficiency tag, as on file with federal regulators (CMS). Older inspection cycles are de-emphasized; only the most recent cycle is current.

Document what happened

Were you or a loved one harmed at Franciscan Woods?

Share a few details to put your inquiry on file. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. As qualified attorneys join our network in your area, one may reach out — we can’t guarantee contact yet, so we encourage you to consult a qualified attorney promptly on your own as well. There is no cost, and your information is handled with care.

Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.

Step 1 of 3 · What happened

Your relationship to the resident
What happened? Select all that apply.

Physical injury

Skin & wounds

Medical & clinical

Safety & abuse

Loss

Something else

The resident is…