Wisconsin › Waukesha County › Brookfield
Franciscan Woods
19525 W North Ave, Brookfield, WI 53045
Ratings are based on the most recent data available; a facility's ratings may have changed since the last update. The health inspection rating is based on the three most recent standard surveys and complaint investigations. CMS processed this record on 1 Aug 2026. View the Care Compare record.
Franciscan Woods is a Non-profit, corporation nursing home in Brookfield, Wisconsin, certified for 110 beds and caring for about 55 residents a day.
CMS gives it 1 of 5 stars overall, below the Wisconsin median of 3; the health inspection rating is 1, staffing 4 and quality measures 2.
Inspectors recorded 50 health deficiencies across the three most recent survey cycles (17, 25, 8 by cycle, most recent first), 5 of them at the actual-harm or immediate-jeopardy level. That is 45.5 per 100 beds, more than the state median of 31.8.
CMS lists 3 penalties in the period covered: fines totalling $121K and 2 payment denials.
Reported nurse staffing is 4.4 hours per resident per day (1.0 RN), close to the Wisconsin median of 4.0; nursing staff turnover is 76.0%.
Compared with county, state and nation
| Measure | This facility | Waukesha Co. median | Wisconsin median | US average |
|---|---|---|---|---|
| Overall star rating | 1 | 1 | 3 | 3.0 |
| Health citations, 3 cycles | 50 | 37 | 21 | 28.7 |
| Citations per 100 beds | 45.5 | 45.5 | 31.8 | 26.8 |
| Total nurse hours per resident day | 4.4 | 4.1 | 4.0 | 3.9 |
| RN hours per resident day | 1.0 | 0.7 | 0.9 | 0.7 |
| Nursing staff turnover | 76.0% | 55.8% | 46.2% | 45.8% |
| Fines listed | $120,905 | $95,791 | $0 | — |
County and state figures are medians across facilities (17 in the county, 323 in the state); the US column is the CMS national average where CMS publishes one.
Citations by survey cycle
Dark bar: this facility. Grey bar: Wisconsin average per facility for the same cycle, as published by CMS. Standard health survey dates: 9 Apr 2026, 14 Nov 2024.
Severity mix: G ×5 D ×32 E ×7 F ×4 C ×2
Health deficiencies
Every health citation in the current CMS record (three survey cycles), most recent first. Tag text is the CMS requirement summary, not the inspection narrative.
Scope and severity letters (A–L)
| Survey date | Tag | What the tag requires | Severity | Type | Corrected |
|---|---|---|---|---|---|
| 9 Apr 2026 | F0880 | Provide and implement an infection prevention and control program. | F | Standard survey | 8 May 2026 |
| 9 Apr 2026 | F0881 | Implement a program that monitors antibiotic use. | F | Standard survey | 8 May 2026 |
| 9 Apr 2026 | F0552 | Ensure that residents are fully informed and understand their health status, care and treatments. | D | Standard survey | 8 May 2026 |
| 9 Apr 2026 | F0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D | Standard survey | 8 May 2026 |
| 9 Apr 2026 | F0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | D | Standard survey | 8 May 2026 |
| 9 Apr 2026 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard survey | 8 May 2026 |
| 9 Apr 2026 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard survey | 8 May 2026 |
| 9 Apr 2026 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 8 May 2026 |
| 9 Apr 2026 | F0693 | 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. | D | Standard survey | 8 May 2026 |
| 9 Apr 2026 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard survey | 8 May 2026 |
| 9 Apr 2026 | F0761 | 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. | D | Standard survey | 8 May 2026 |
| 9 Apr 2026 | F0849 | 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. | D | Standard survey | 8 May 2026 |
| 9 Apr 2026 | F0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Standard survey | 8 May 2026 |
| 9 Apr 2026 | F0887 | 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 | Standard survey | 8 May 2026 |
| 22 Dec 2025 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Complaint investigation | 3 Feb 2026 |
| 22 Dec 2025 | F0759 | Ensure medication error rates are not 5 percent or greater. | D | Complaint investigation | 3 Feb 2026 |
| 3 Dec 2025 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint investigation | 19 Dec 2025 |
| 6 May 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint investigation | 2 Jun 2025 |
| 6 May 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint investigation | 2 Jun 2025 |
| 6 May 2025 | F0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | Complaint investigation | 2 Jun 2025 |
| 20 Mar 2025 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Complaint investigation | 18 Jun 2025 |
| 20 Mar 2025 | F0692 | Provide enough food/fluids to maintain a resident's health. | G | Complaint investigation | 23 Apr 2025 |
| 20 Mar 2025 | F0880 | Provide and implement an infection prevention and control program. | F | Complaint investigation | 2 Jun 2025 |
| 20 Mar 2025 | F0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | E | Complaint investigation | 23 Apr 2025 |
| 20 Mar 2025 | F0610 | Respond appropriately to all alleged violations. | E | Complaint investigation | 23 Apr 2025 |
| 20 Mar 2025 | F0585 | 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. | D | Complaint investigation | 23 Apr 2025 |
| 20 Mar 2025 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 23 Apr 2025 |
| 20 Mar 2025 | F0700 | 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 | Complaint investigation | 23 Apr 2025 |
| 11 Feb 2025 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Complaint investigation | 18 Jun 2025 |
| 11 Feb 2025 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint investigation | 12 Mar 2025 |
| 14 Jan 2025 | F0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | Complaint investigation | 14 Feb 2025 |
| 23 Dec 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint investigation | 23 Jan 2025 |
| 14 Nov 2024 | F0693 | 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. | G | Complaint investigation | 10 Dec 2024 |
| 14 Nov 2024 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F | Complaint investigation | 10 Dec 2024 |
| 14 Nov 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard survey | 10 Dec 2024 |
| 14 Nov 2024 | F0880 | Provide and implement an infection prevention and control program. | E | Standard survey | 10 Dec 2024 |
| 14 Nov 2024 | F0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint investigation | 10 Dec 2024 |
| 14 Nov 2024 | F0585 | 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. | D | Standard survey | 10 Dec 2024 |
| 14 Nov 2024 | F0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | Standard survey | 10 Dec 2024 |
| 14 Nov 2024 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint investigation | 10 Dec 2024 |
| 14 Nov 2024 | F0758 | 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 | Standard survey | 10 Dec 2024 |
| 14 Nov 2024 | F0732 | Post nurse staffing information every day. | C | Standard survey | 10 Dec 2024 |
| 5 Apr 2024 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E | Complaint investigation | 5 May 2024 |
| 5 Oct 2023 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | E | Complaint investigation | 4 Nov 2023 |
| 5 Oct 2023 | F0610 | Respond appropriately to all alleged violations. | E | Complaint investigation | 4 Nov 2023 |
| 5 Oct 2023 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint investigation | 4 Nov 2023 |
| 5 Oct 2023 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard survey | 4 Nov 2023 |
| 5 Oct 2023 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard survey | 4 Nov 2023 |
| 5 Oct 2023 | F0758 | 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 | Standard survey | 4 Nov 2023 |
| 5 Oct 2023 | F0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | C | Complaint investigation | 4 Nov 2023 |
Penalties
| Date | Type | Amount | Detail |
|---|---|---|---|
| 11 Feb 2025 | Payment denial | — | 97 days |
| 11 Feb 2025 | Fine | $120,905 | |
| 14 Nov 2024 | Payment denial | — | 31 days |
Staffing
Hours per resident per day as reported through the Payroll-Based Journal; grey bars are the Wisconsin average. Turnover: nursing staff 76.0%, RNs 27.3%; 2 administrators left in the reporting year.
Quality measures
| Measure | Residents | This facility | Wisconsin median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 20.9% | 15.4% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | 1.5% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.5% | 2.3% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 1.0% | 3.0% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.9% | 0.9% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 34.4% | 16.8% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 7.7% | 4.4% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 13.4% | 14.4% | 13.4% |
Four-quarter averages for the measures CMS uses in the quality-measure star rating (2025Q2-2026Q1). Lower is better for every measure listed. Medians are computed across facilities on this site.
Ownership
Ownership type: non-profit, corporation. Legal business name: Wheaton Franciscan Healthcare Terrace At St. Francis, Inc.. Chain: Ascension Living (12 facilities).
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| Ascension Health Senior Care | 5% or greater direct ownership interest | 100% | 07/01/2014 |
| Ascension Health Senior Care | Adp of the snf | NOT APPLICABLE | 07/01/2015 |
| Fast Pace Medical Staffing Inc | Adp of the snf | NOT APPLICABLE | 10/07/2022 |
| Favorite Healthcare Staffing LLC | Adp of the snf | NOT APPLICABLE | 10/14/2022 |
| Health Dimensions Consulting Inc | Adp of the snf | NOT APPLICABLE | 04/29/2025 |
| House Healthcare Solutions LLC | Adp of the snf | NOT APPLICABLE | 06/10/2025 |
| Medical Solutions LLC | Adp of the snf | NOT APPLICABLE | 06/14/2017 |
| Medical Staffing Solutions LLC | Adp of the snf | NOT APPLICABLE | 10/06/2020 |
| Nursing Centers, Inc. | Adp of the snf | NOT APPLICABLE | 06/08/2020 |
| Personnel Specialists LLC | Adp of the snf | NOT APPLICABLE | 04/10/2025 |
| Prn Health Services, Inc. | Adp of the snf | NOT APPLICABLE | 08/19/2022 |
| Prolink Healthcare LLC | Adp of the snf | NOT APPLICABLE | 04/26/2023 |
| Staff One, Ltd. | Adp of the snf | NOT APPLICABLE | 04/27/2020 |
Only organisations are shown. CMS also records individual owners, officers and managing employees; this site does not publish people's names.
Other nursing homes in Waukesha County
| Facility | City | Beds | Overall | Health | Staffing | Citations | Per 100 beds | Fines | Last survey |
|---|---|---|---|---|---|---|---|---|---|
| Masonic Center For Health & Rehab Inc. | Dousman | 50 | 5 | 5 | 5 | 3 | 6.0 | — | 29 Jan 2026 |
| Shorehaven Hlth & Rehab Ctr | Oconomowoc | 88 | 5 | 4 | 5 | 10 | 11.4 | — | 5 Mar 2026 |
| Congregational Home, Inc. | Brookfield | 66 | 4 | 3 | 5 | 21 | 31.8 | — | 31 Jul 2025 |
| Lake Country Health Services | Oconomowoc | 100 | 2 | 2 | 3 | 42 | 42.0 | $121K | 27 Aug 2025 |
| Lindengrove Mukwonago | Mukwonago | 47 | 2 | 3 | 4 | 25 | 53.2 | — | 10 Dec 2025 |
| Menomonee Falls Health Services | Menomonee Falls | 50 | 2 | 2 | 3 | 46 | 92.0 | $214K | 3 Dec 2025 |
| Muskego Health and Rehabilitation Center | Muskego | 49 | 2 | 2 | 3 | 56 | 114.3 | — | 28 Jan 2026 |
| Tudor Oaks Health Center | Muskego | 50 | 2 | 2 | 3 | 37 | 74.0 | $181K | 5 Dec 2025 |
All 17 facilities in Waukesha County
Questions and answers
How many deficiencies has Franciscan Woods been cited for?
50 health deficiencies across the three most recent survey cycles, 5 at the actual-harm or immediate-jeopardy level. The Wisconsin median is 21 per facility.
Has Franciscan Woods been fined?
Yes. CMS lists fines totalling $121K in the period covered, plus 2 payment denials.
How does staffing at Franciscan Woods compare?
Reported total nurse staffing is 4.4 hours per resident per day against a Wisconsin median of 4.0 and a national average of 3.9.
Who operates Franciscan Woods?
It is part of the Ascension Living chain. Ownership type is non-profit, corporation. Organisations in the CMS ownership record include Ascension Health Senior Care. Individual owners and managers are not listed on this site.
When was Franciscan Woods last inspected?
The most recent survey or investigation in the CMS record is dated 9 Apr 2026; the most recent standard health survey was 9 Apr 2026.
Where does this data come from?
All figures are from the Centers for Medicare & Medicaid Services Care Compare datasets (provider information, health deficiencies, penalties, ownership and quality measures), processed 1 Aug 2026. Ratings and citations may change; the Care Compare record is authoritative.
Provenance
Source: Centers for Medicare & Medicaid Services, Care Compare nursing home datasets (provider information, health deficiencies, penalties, ownership, MDS quality measures, state and national averages), public domain, processed by CMS on 1 Aug 2026. Facility record: Care Compare. Errors in processing are corrected at the next daily build; see corrections.