Franciscan Woods
Brookfield, Waukesha County, Wisconsin · CCN 525528 · Non-profit (Corporation) · part of Ascension Living (12 facilities, chain average 2.8 stars)
CMS rates Franciscan Woods 1 of 5 overall as of August 2026. 110 certified beds, 55 residents a day on average. 50 citations on record from the current inspection cycles, 5 involving actual harm; 1 fine totalling $120,905 and 2 payment denials.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★★★☆ 4 of 5 |
| Quality measures | ★★☆☆☆ 2 of 5 |
| Quality: long-stay / short-stay | 2 / 3 of 5 |
Staffing
| Total nurse staffing | 4.38995 hours per resident per day |
|---|---|
| Registered nurses | 0.95046 hours per resident per day |
| Weekend total | 3.66596 hours per resident per day |
| Nursing staff turnover | 76% (registered nurses 27.3%) |
| Administrators who left | 2 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-04-09 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-05-08 |
| 2026-04-09 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · tag F0881 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-05-08 |
| 2026-04-09 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · tag F0552 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-08 |
| 2026-04-09 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · tag F0628 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Quality of Life and Care Deficiencies · tag F0676 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-08 |
| 2026-04-09 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-08 |
| 2026-04-09 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-08 |
| 2026-04-09 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Quality of Life and Care Deficiencies · tag F0693 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Administration Deficiencies · tag F0849 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-08 |
| 2026-04-09 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Infection Control Deficiencies · tag F0887 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-08 |
| 2025-12-22 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2026-02-03 |
| 2025-12-22 complaint survey |
Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-03 |
| 2025-12-03 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-12-19 |
| 2025-05-06 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-06-02 |
| 2025-05-06 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-06-02 |
| 2025-05-06 complaint survey |
Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-06-02 |
| 2025-03-20 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-06-18 |
| 2025-03-20 complaint survey |
Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-04-23 |
| 2025-03-20 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-06-02 |
| 2025-03-20 complaint survey |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-23 |
| 2025-03-20 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-23 |
| 2025-03-20 complaint survey |
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. Resident Rights Deficiencies · tag F0585 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-23 |
| 2025-03-20 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-23 |
| 2025-03-20 complaint survey |
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. Quality of Life and Care Deficiencies · tag F0700 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-23 |
| 2025-02-11 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-06-18 |
| 2025-02-11 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-12 |
| 2025-01-14 complaint survey |
Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-14 |
| 2024-12-23 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-23 |
| 2024-11-14 complaint survey |
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. Quality of Life and Care Deficiencies · tag F0693 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-12-10 |
| 2024-11-14 complaint survey |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-10 |
| 2024-11-14 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-10 |
| 2024-11-14 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Resident Rights Deficiencies · tag F0585 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Resident Rights Deficiencies · tag F0623 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-10 |
| 2024-11-14 complaint survey |
Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-10 |
| 2024-11-14 | 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-10 |
| 2024-11-14 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2024-12-10 |
| 2024-04-05 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-05-05 |
| 2023-10-05 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-04 |
| 2023-10-05 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-04 |
| 2023-10-05 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-04 |
| 2023-10-05 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-04 |
| 2023-10-05 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-04 |
| 2023-10-05 | 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-04 |
| 2023-10-05 complaint survey |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2023-11-04 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2025-02-11 | Payment denial for 97 days from 2025-03-13 | — |
| 2025-02-11 | Fine | $120,905 |
| 2024-11-14 | Payment denial for 31 days from 2024-12-14 | — |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Ascension Health Senior Care Organization | 5% or greater direct ownership interest | 100% | 2014-07-01 |
| Ascension Health Senior Care Organization | adp of the snf | — | 2015-07-01 |
| Fast Pace Medical Staffing Inc. Organization | adp of the snf | — | 2022-10-07 |
| Favorite Healthcare Staffing LLC Organization | adp of the snf | — | 2022-10-14 |
| Health Dimensions Consulting Inc. Organization | adp of the snf | — | 2025-04-29 |
| House Healthcare Solutions LLC Organization | adp of the snf | — | 2025-06-10 |
| Medical Solutions LLC Organization | adp of the snf | — | 2017-06-14 |
| Medical Staffing Solutions LLC Organization | adp of the snf | — | 2020-10-06 |
| Michael Porter Organization | adp of the snf | — | 2021-05-09 |
| Nursing Centers, Inc. Organization | adp of the snf | — | 2020-06-08 |
| Personnel Specialists LLC Organization | adp of the snf | — | 2025-04-10 |
| Prn Health Services, Inc. Organization | adp of the snf | — | 2022-08-19 |
| Prolink Healthcare LLC Organization | adp of the snf | — | 2023-04-26 |
| Staff One, Ltd. Organization | adp of the snf | — | 2020-04-27 |
| Musgrave, Lisa Individual | adp of the snf | — | 2024-01-01 |
| Shadbolt, Erin Individual | adp of the snf | — | 2024-01-01 |
| Sidhu, Sarfraz Individual | adp of the snf | — | 2018-11-01 |
| Smoot, Kenneth Individual | adp of the snf | — | 2024-01-01 |
| St Louis, Steven Individual | adp of the snf | — | 2025-01-23 |
| Musgrave, Lisa Individual | corporate director | — | 2024-01-01 |
| Shadbolt, Erin Individual | corporate director | — | 2024-01-01 |
| Smoot, Kenneth Individual | corporate director | — | 2024-01-01 |
| Sidhu, Sarfraz Individual | operational/managerial control | — | 2018-11-01 |
| St Louis, Steven Individual | operational/managerial control | — | 2025-01-23 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Franciscan Woods.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Waukesha County.