Facility Watch Inspection records for every certified US nursing home

Franciscan Woods

19525 W North AVE
Brookfield, WI 53045
(262) 785-1114

CCN
525528
Certified beds
110
Ownership
Non profit - Corporation
Chain
Ascension Living

Nurse staffing

4.01
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.76 hours per resident per day

Nursing staff turnover: 76% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected December 22, 2025

2 citations · from a complaint investigation · Health
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected February 3, 2026
G
F0686 Actual harm · Isolated

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

Deficient, Provider has date of correction · corrected February 3, 2026

Inspected December 3, 2025

1 citation · from a complaint investigation · Health
D
F0600 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected December 19, 2025

Inspected May 6, 2025

3 citations · from a complaint investigation · Health
D
F0689 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 2, 2025
D
F0755 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 2, 2025
D
F0757 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 2, 2025

Inspected March 20, 2025

8 citations · from a complaint investigation · Health
D
F0585 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected April 23, 2025
D
F0609 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected April 23, 2025
D
F0700 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected April 23, 2025
E
F0607 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected April 23, 2025
E
F0610 No actual harm with potential for more than minimal harm · Pattern

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected April 23, 2025
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected June 2, 2025
G
F0686 Actual harm · Isolated

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

Deficient, Provider has date of correction · corrected June 18, 2025
G
F0692 Actual harm · Isolated

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

Deficient, Provider has date of correction · corrected April 23, 2025

Inspected February 11, 2025

2 citations · from a complaint investigation · Health
D
F0684 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected March 12, 2025
G
F0686 Actual harm · Isolated

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

Deficient, Provider has date of correction · corrected June 18, 2025

Inspected January 14, 2025

1 citation · from a complaint investigation · Health
D
F0757 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected February 14, 2025

Inspected December 23, 2024

1 citation · from a complaint investigation · Health
D
F0755 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected January 23, 2025

Inspected November 14, 2024

10 citations · from a complaint investigation · Health
C
F0732 No actual harm with potential for minimal harm · Widespread

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected December 10, 2024
D
F0580 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected December 10, 2024
D
F0585 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected December 10, 2024
D
F0623 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected December 10, 2024
D
F0677 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected December 10, 2024
D
F0758 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected December 10, 2024
E
F0812 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected December 10, 2024
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected December 10, 2024
F
F0725 No actual harm with potential for more than minimal harm · Widespread

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

Deficient, Provider has date of correction · corrected December 10, 2024
G
F0693 Actual harm · Isolated

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.

Deficient, Provider has date of correction · corrected December 10, 2024

Inspected April 5, 2024

1 citation · from a complaint investigation · Health
E
F0842 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected May 5, 2024

Inspected October 5, 2023

7 citations · from a complaint investigation · Health
C
F0607 No actual harm with potential for minimal harm · Widespread

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

Deficient, Provider has date of correction · corrected November 4, 2023
D
F0684 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected November 4, 2023
D
F0686 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected November 4, 2023
D
F0755 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected November 4, 2023
D
F0758 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected November 4, 2023
E
F0609 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected November 4, 2023
E
F0610 No actual harm with potential for more than minimal harm · Pattern

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected November 4, 2023

Inspected July 18, 2022

15 citations · Health
D
F0582 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 16, 2022
D
F0609 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 16, 2022
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected August 16, 2022
D
F0623 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 16, 2022
D
F0625 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected August 16, 2022
D
F0660 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 16, 2022
D
F0661 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 16, 2022
D
F0695 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 16, 2022
D
F0740 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 16, 2022
D
F0756 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 16, 2022
D
F0758 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected August 16, 2022
D
F0812 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 16, 2022
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected August 16, 2022
E
F0607 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected August 16, 2022
G
F0684 Actual harm · Isolated

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

Deficient, Provider has date of correction · corrected August 16, 2022

Penalties

DateTypeAmount
February 11, 2025Fine$120,214
February 11, 2025Payment Denial · 97 days
November 14, 2024Payment Denial · 31 days