Franciscan Woods
19525 W North Ave, Brookfield, WI 53045 · Waukesha County · 110 certified beds · avg 55 residents/day · certified since Dec 30, 1993
Part of chain: ASCENSION LIVING (12 facilities, chain avg rating 2.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Dec 22, 2025 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 3, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 20, 2025 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 18, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 20, 2025 · F-0692 · triggered by a complaint
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 23, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 11, 2025 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 18, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 14, 2024 · F-0693 · triggered by a complaint
The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Why it matters: Unnecessary or poorly managed feeding tubes can cause serious complications like lung infections and take away the ability to eat normally.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 10, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (50)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 9, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 9, 2026 | F · Potential for harm, facility-wide | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Dec 22, 2025 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Dec 22, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint |
| Dec 3, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 6, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 6, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| May 6, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint |
| Mar 20, 2025 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Mar 20, 2025 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Mar 20, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Mar 20, 2025 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Mar 20, 2025 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · from a complaint |
| Feb 11, 2025 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Feb 11, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jan 14, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint |
| Dec 23, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Nov 14, 2024 | ▲ G · Actual harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Nov 14, 2024 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Nov 14, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 14, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 14, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Nov 14, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Nov 14, 2024 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Nov 14, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Nov 14, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Nov 14, 2024 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Apr 5, 2024 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Oct 5, 2023 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 5, 2023 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Oct 5, 2023 | C · Minimal risk, facility-wide | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (10 → 14).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 0 | E |
| 2024 | 12 | 1 | G ▲ |
| 2025 | 17 | 4 | G ▲ |
| 2026 | 14 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $120,905, plus 2 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Feb 11, 2025 | Fine | $120,905 |
| Feb 11, 2025 | Payment Denial | 97 days from Mar 13, 2025 |
| Nov 14, 2024 | Payment Denial | 31 days from Dec 14, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.40 | 4.29 | 3.95 | top 40% in Wisconsin; top 26% in the U.S. |
| Registered Nurse hours | 0.95 | 1.01 | 0.69 | top 47% in Wisconsin; top 18% in the U.S. |
| Weekend total nurse staffing | 3.67 | 3.84 | 3.50 | top 49% in Wisconsin; top 34% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.46 | 0.68 | 0.48 | bottom 27% in Wisconsin; top 38% in the U.S. |
| Total nursing staff turnover (%) | 76.0 | 46.9 | 45.8 | bottom 2% in Wisconsin; bottom 3% in the U.S. |
| RN turnover (%) | 27.3 | 39.7 | 42.9 | top 30% in Wisconsin; top 24% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.39, RN 0.95, weekend 3.67. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ascension Health Senior Care | Organization | 5% or Greater Direct Ownership Interest | 100% | 07/01/2014 |
| Ascension Health Senior Care | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2015 |
| Fast Pace Medical Staffing INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/07/2022 |
| Favorite Healthcare Staffing LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/14/2022 |
| Health Dimensions Consulting INC | Organization | ADP of the SNF | NOT APPLICABLE | 04/29/2025 |
| House Healthcare Solutions LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/10/2025 |
| Medical Solutions LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/14/2017 |
| Medical Staffing Solutions LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/06/2020 |
| Michael Porter | Organization | ADP of the SNF | NOT APPLICABLE | 05/09/2021 |
| Musgrave, Lisa | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Musgrave, Lisa | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Nursing Centers, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 06/08/2020 |
| Personnel Specialists LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/10/2025 |
| PRN Health Services, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 08/19/2022 |
| Prolink Healthcare LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/26/2023 |
| Shadbolt, Erin | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Shadbolt, Erin | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Sidhu, Sarfraz | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2018 |
| Sidhu, Sarfraz | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2018 |
| Smoot, Kenneth | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How do you decide when a feeding tube is truly needed, and how do staff care for residents who have one?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
- "How do you explain health changes and treatment options to residents and their families?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Complete Care at Care Age | 0.7 mi | Brookfield, WI | ★☆☆☆☆ | 1/5 | |
| Aria of Brookfield | 1.9 mi | Brookfield, WI | ★☆☆☆☆ | 1/5 | abuse |
| Congregational Home, INC. | 3.7 mi | Brookfield, WI | ★★★★☆ | 3/5 | |
| Aria of Waukesha | 4.0 mi | Waukesha, WI | ★☆☆☆☆ | 2/5 | |
| Lindengrove New Berlin | 6.1 mi | New Berlin, WI | ★☆☆☆☆ | 1/5 | |
| St Camillus Health Center | 6.1 mi | Wauwatosa, WI | ★★☆☆☆ | 1/5 | |
| Menomonee Falls Health Services | 6.2 mi | Menomonee Falls, WI | ★★☆☆☆ | 2/5 | |
| Lindengrove Menomonee Falls | 6.2 mi | Menomonee Falls, WI | ★☆☆☆☆ | 1/5 | |
| Lindengrove Waukesha | 6.4 mi | Waukesha, WI | ★☆☆☆☆ | 1/5 | |
| Avina of Pewaukee | 6.5 mi | Waukesha, WI | ★☆☆☆☆ | 1/5 | |
| Complete Care at Kensington | 6.5 mi | Waukesha, WI | ★☆☆☆☆ | 2/5 | |
| St. Anne's Salvatorian Campus | 6.7 mi | Milwaukee, WI | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 525528.