Franciscan Woods

Waukesha · WI · Non profit - Corporation · ASCENSION LIVING chain · 110 certified beds · CCN 525528 · WHEATON FRANCISCAN HEALTHCARE TERRACE AT ST. FRANCIS, INC.


Franciscan Woods operates 110 certified beds in BROOKFIELD, Wisconsin. Its Medicare and Medicaid certification dates to 1993-12-30. It averages 55.3 residents a day.

What harm was found in the violations cited at Franciscan Woods?

CMS lists 50 health-inspection deficiencies for Franciscan Woods, all of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is G; the most recent health inspection was 2026-04-09.

Survey dateTagDeficiencySeverity
2026-04-09F0880, F0881Provide and implement an infection prevention and control program. / Implement a program that monitors antibiotic use.F
2026-04-09F0552, F0628, F0676, F0684, F0686, F0689, F0693, F0755, F0761, F0849, F0883, F0887Ensure that residents are fully informed and understand their health status, care and treatments. / Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. / Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / 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. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / 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. / 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. / Develop and implement policies and procedures for flu and pneumonia vaccinations. / 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.D
2025-12-22F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.G
2025-12-22F0759Ensure medication error rates are not 5 percent or greater.D
2025-12-03F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D
2025-05-06F0689, F0755, F0757Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Ensure each resident’s drug regimen must be free from unnecessary drugs.D
2025-03-20F0686, F0692Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Provide enough food/fluids to maintain a resident's health.G
2025-03-20F0880Provide and implement an infection prevention and control program.F
2025-03-20F0607, F0610Develop and implement policies and procedures to prevent abuse, neglect, and theft. / Respond appropriately to all alleged violations.E
2025-03-20F0585, F0609, F0700Honor 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. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / 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.D
2025-02-11F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.G
2025-02-11F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.D
2025-01-14F0757Ensure each resident’s drug regimen must be free from unnecessary drugs.D
2024-12-23F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D
2024-11-14F0693Ensure 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.G
2024-11-14F0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.F
2024-11-14F0812, F0880Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Provide and implement an infection prevention and control program.E
2024-11-14F0580, F0585, F0623, F0677, F0758Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / 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. / Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. / Provide care and assistance to perform activities of daily living for any resident who is unable. / 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.D
2024-11-14F0732Post nurse staffing information every day.C
2024-04-05F0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.E
2023-10-05F0609, F0610Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations.E
2023-10-05F0684, F0686, F0755, F0758Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / 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.D
2023-10-05F0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.C

Why was Franciscan Woods fined?

DateTypeAmount
2025-02-11Fine$120,905

Has Franciscan Woods had payment denied by Medicare more than once?

Payment denial startLength in days
2025-03-1397
2024-12-1431

How is Franciscan Woods staffed?

MeasureThis facilityWI average
Total nurse staffing hours per resident per day4.389954.21234
Total nursing staff turnover (%)76.046.9
Average number of residents per day55.354.8

Who owns Franciscan Woods, and what chain is it in?

Franciscan Woods is registered with CMS as Non profit - Corporation, operates under the legal business name WHEATON FRANCISCAN HEALTHCARE TERRACE AT ST. FRANCIS, INC. and belongs to the ASCENSION LIVING chain.

RoleOwnerAssociation date
5% OR GREATER DIRECT OWNERSHIP INTERESTASCENSION HEALTH SENIOR CAREsince 07/01/2014
CORPORATE DIRECTORMUSGRAVE, LISA, SHADBOLT, ERIN, SMOOT, KENNETHsince 01/01/2024
OPERATIONAL/MANAGERIAL CONTROLSIDHU, SARFRAZ, ST LOUIS, STEVENsince 01/23/2025
ADP OF THE SNFASCENSION HEALTH SENIOR CARE, FAST PACE MEDICAL STAFFING INC, FAVORITE HEALTHCARE STAFFING LLC, HEALTH DIMENSIONS CONSULTING INC, HOUSE HEALTHCARE SOLUTIONS LLC, MEDICAL SOLUTIONS LLC, MEDICAL STAFFING SOLUTIONS LLC, MICHAEL PORTER, NURSING CENTERS, INC., PERSONNEL SPECIALISTS LLC, PRN HEALTH SERVICES, INC., PROLINK HEALTHCARE LLC, STAFF ONE, LTD., MUSGRAVE, LISA, SHADBOLT, ERIN, SIDHU, SARFRAZ, SMOOT, KENNETH, ST LOUIS, STEVENsince 01/01/2024

Were you or a family member harmed at Franciscan Woods?