Nursing homes › Wisconsin › Franciscan Woods
19525 W North Ave, Brookfield, WI 53045 · (262) 785-1114 · 110 certified beds
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Open your comparisonCMS overall star rating: this provider 1/5; median among 321 providers with a published value in the same state and provider category: 3/5.
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Per CMS filings, this facility is affiliated with Ascension Living, a group operating 12 facilities in 8 states. Group record: average rating 2.8/5, 1 abuse citation icon, 0 facilities on the Special Focus list, $880,682 in federal fines. This facility rates below its group average (2.8/5).
Total nurse staffing: 4.39 (Wisconsin median: 4.02). RN hours: 0.95. Weekend total: 3.67. Nursing staff turnover: 76%.
In the downloaded CMS dataset: 50 deficiency citations. Below: up to 40 most recent citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-04-09 | Provide and implement an infection prevention and control program. | F | Health | corrected 2026-05-08 |
| 2026-04-09 | Implement a program that monitors antibiotic use. | F | Health | corrected 2026-05-08 |
| 2026-04-09 | Ensure that residents are fully informed and understand their health status, care and treatments. | D | Health | corrected 2026-05-08 |
| 2026-04-09 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D | Health | corrected 2026-05-08 |
| 2026-04-09 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | D | Health | corrected 2026-05-08 |
| 2026-04-09 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Health | corrected 2026-05-08 |
| 2026-04-09 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Health | corrected 2026-05-08 |
| 2026-04-09 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Health | corrected 2026-05-08 |
| 2026-04-09 | 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 | Health | corrected 2026-05-08 |
| 2026-04-09 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Health | corrected 2026-05-08 |
| 2026-04-09 | 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 | Health | corrected 2026-05-08 |
| 2026-04-09 | 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 | Health | corrected 2026-05-08 |
| 2026-04-09 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Health | corrected 2026-05-08 |
| 2026-04-09 | 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 | Health | corrected 2026-05-08 |
| 2025-12-22 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | complaint | corrected 2026-02-03 |
| 2025-12-22 | Ensure medication error rates are not 5 percent or greater. | D | complaint | corrected 2026-02-03 |
| 2025-12-03 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | complaint | corrected 2025-12-19 |
| 2025-05-06 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | complaint | corrected 2025-06-02 |
| 2025-05-06 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | complaint | corrected 2025-06-02 |
| 2025-05-06 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | complaint | corrected 2025-06-02 |
| 2025-03-20 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | complaint | corrected 2025-06-18 |
| 2025-03-20 | Provide enough food/fluids to maintain a resident's health. | G | complaint | corrected 2025-04-23 |
| 2025-03-20 | Provide and implement an infection prevention and control program. | F | complaint | corrected 2025-06-02 |
| 2025-03-20 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | E | complaint | corrected 2025-04-23 |
| 2025-03-20 | Respond appropriately to all alleged violations. | E | complaint | corrected 2025-04-23 |
| 2025-03-20 | 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 | corrected 2025-04-23 |
| 2025-03-20 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | complaint | corrected 2025-04-23 |
| 2025-03-20 | 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 | corrected 2025-04-23 |
| 2025-02-11 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | complaint | corrected 2025-06-18 |
| 2025-02-11 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | corrected 2025-03-12 |
| 2025-01-14 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | complaint | corrected 2025-02-14 |
| 2024-12-23 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | complaint | corrected 2025-01-23 |
| 2024-11-14 | 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 | corrected 2024-12-10 |
| 2024-11-14 | 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 | corrected 2024-12-10 |
| 2024-11-14 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Health | corrected 2024-12-10 |
| 2024-11-14 | Provide and implement an infection prevention and control program. | E | Health | corrected 2024-12-10 |
| 2024-11-14 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | complaint | corrected 2024-12-10 |
| 2024-11-14 | 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 | Health | corrected 2024-12-10 |
| 2024-11-14 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | Health | corrected 2024-12-10 |
| 2024-11-14 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | complaint | corrected 2024-12-10 |
| Date | Type | Amount |
|---|---|---|
| 2025-02-11 | Fine | $120,905 |
| 2025-02-11 | Payment Denial | 97 days payment denial |
| 2024-11-14 | Payment Denial | 31 days payment denial |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| ASCENSION HEALTH SENIOR CARE | 5% Or Greater Direct Ownership Interest | Organization | 100% | since 07/01/2014 |
| MUSGRAVE, LISA | Corporate Director | Individual | NOT APPLICABLE | since 01/01/2024 |
| SHADBOLT, ERIN | Corporate Director | Individual | NOT APPLICABLE | since 01/01/2024 |
| SMOOT, KENNETH | Corporate Director | Individual | NOT APPLICABLE | since 01/01/2024 |
| SIDHU, SARFRAZ | Operational/Managerial Control | Individual | NOT APPLICABLE | since 11/01/2018 |
| ST LOUIS, STEVEN | Operational/Managerial Control | Individual | NOT APPLICABLE | since 01/23/2025 |
How to cite this page: CareRecords, “Franciscan Woods — compliance, penalty and ownership record” (CCN 525528), compiled from the CMS Provider Data Catalog, August 2026 release. https://carerecords.org/nursing-home/franciscan-woods-brookfield-wi/
Source: CMS Provider Data Catalog (August 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 525528. Corrections: data@carerecords.org.