Franciscan Woods
19525 W North Ave, Brookfield, WI 53045
Franciscan Woods is a nursing home in Brookfield, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (262) 785-1114
- Last standard health inspection
- April 9, 2026 (7 months ago)
- Certified beds
- 110
- Residents per day, on average
- 50.5
- Ownership type
- Non profit - Corporation
- Legal business name
- Wheaton Franciscan Healthcare Terrace at St. Francis, INC.
- Chain
- Ascension Living
- Takes part in
- Medicare and Medicaid
More health citations than the Wisconsin average (54 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.4 to 3.8 hours per resident per day.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Fine
CMS changed the fine from February 11, 2025 from $120,214 to $120,905.
4 citations
Health inspection on July 23, 2026
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
63 of 323 Wisconsin homes (20%) got a citation at the actual harm level in 2026.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 19, 2026.
CMS has cited this home for F0689 3 times since 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on August 19, 2026.
CMS has cited this home for F0609 3 times since 2023.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on August 19, 2026.
CMS has cited this home for F0610 3 times since 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on August 19, 2026.
CMS has cited this home for F0684 4 times since 2023.
CMS update of May 27, 2026
Fine
CMS changed the fine from February 11, 2025 from $118,144 to $120,214.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
14 citations
Health inspection on April 9, 2026
CMS lists this as a standard inspection.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 8, 2026.
CMS has cited this home for F0880 3 times since 2024.
Citation F0881. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on May 8, 2026.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on May 8, 2026.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on May 8, 2026.
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on May 8, 2026.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 8, 2026.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on May 8, 2026.
CMS has cited this home for F0686 5 times since 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 8, 2026.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 8, 2026.
CMS has cited this home for F0693 2 times since 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 8, 2026.
CMS has cited this home for F0755 4 times since 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 8, 2026.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 8, 2026.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on May 8, 2026.
Citation F0887. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 8, 2026.
5 citations
Fire safety inspection on April 9, 2026
CMS lists this as a standard inspection.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on May 30, 2026.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 8, 2026.
CMS has cited this home for K0353 3 times since 2023.
Citation K0364. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install properly constructed windows in hallway walls or doors.
CMS lists it as corrected on May 30, 2026.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on October 13, 2026.
Citation K0916. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a battery powered remote alarm panel in a location accessible by operating personnel.
CMS lists it as corrected on May 8, 2026.
CMS update of February 25, 2026
Fine
CMS changed the fine from February 11, 2025 from $181,760 to $118,144.
2 citations
Health inspection on December 22, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
77 of 323 Wisconsin homes (24%) got a citation at the actual harm level in 2025.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on February 3, 2026.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on February 3, 2026.
Fine
December 22, 2025 (10 months ago)
CMS fine of $81,840 on December 22, 2025.
1 citation
Health inspection on December 3, 2025
CMS lists this as a complaint inspection.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on December 19, 2025.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
3 citations
Health inspection on May 6, 2025
CMS lists this as a complaint inspection.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 2, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on June 2, 2025.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on June 2, 2025.
CMS has cited this home for F0757 2 times since 2025.
8 citations
Health inspection on March 20, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
77 of 323 Wisconsin homes (24%) got a citation at the actual harm level in 2025.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on June 18, 2025.
Citation F0692. Severity G: actual harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 23, 2025.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 2, 2025.
Citation F0607. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on April 23, 2025.
CMS has cited this home for F0607 2 times since 2023.
Citation F0610. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on April 23, 2025.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 23, 2025.
CMS has cited this home for F0585 2 times since 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on April 23, 2025.
Citation F0700. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 23, 2025.
Payment stopped
March 13, 2025 (1 year ago)
CMS stopped payment for new admissions from March 13, 2025, for 97 days.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
2 citations
Health inspection on February 11, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
77 of 323 Wisconsin homes (24%) got a citation at the actual harm level in 2025.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on June 18, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on March 12, 2025.
Fine
February 11, 2025 (1 year ago)
CMS fine of $120,905 on February 11, 2025.
1 citation
Health inspection on January 14, 2025
CMS lists this as a complaint inspection.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on February 14, 2025.
1 citation
Health inspection on December 23, 2024
CMS lists this as a complaint inspection.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on January 23, 2025.
Payment stopped
December 14, 2024 (1 year ago)
CMS stopped payment for new admissions from December 14, 2024, for 31 days.
10 citations
Health inspection on November 14, 2024
CMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
67 of 323 Wisconsin homes (21%) got a citation at the actual harm level in 2024.
Citation F0693. Severity G: actual harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 10, 2024.
Citation F0725. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on December 10, 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on December 10, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 10, 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on December 10, 2024.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 10, 2024.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on December 10, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on December 10, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 10, 2024.
CMS has cited this home for F0758 2 times since 2023.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on December 10, 2024.
9 citations
Fire safety inspection on November 14, 2024
CMS lists this as a standard inspection.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on January 8, 2025.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on January 8, 2025.
Citation K0751. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have restrictions on the use of flammable curtains.
CMS lists it as corrected on January 8, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
Citation E0013. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop Emergency Preparedness policies and procedures.
CMS lists it as corrected on January 8, 2025.
Citation E0015. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on January 8, 2025.
Citation K0211. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on January 14, 2025.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on January 13, 2025.
Citation K0925. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
CMS lists it as corrected on January 8, 2025.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
CMS update of September 26, 2024
Fine
CMS changed the fine from July 18, 2022 from $28,091 to $28,725.
CMS update of August 29, 2024
Name
CMS lists a new legal business name for this home.
CMS update of June 26, 2024
Fine
CMS changed the fine from July 18, 2022 from $27,073 to $28,091.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
1 citation
Health inspection on April 5, 2024
CMS lists this as a complaint inspection.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on May 5, 2024.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Fine
CMS changed the fine from July 18, 2022 from $41,650 to $27,073.
7 citations
Health inspection on October 5, 2023
CMS lists this as a standard inspection and a complaint inspection.
Citation F0609. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on November 4, 2023.
Citation F0610. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on November 4, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on November 4, 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on November 4, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on November 4, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 4, 2023.
Citation F0607. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on November 4, 2023.
3 citations
Fire safety inspection on October 5, 2023
CMS lists this as a standard inspection.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on November 4, 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on November 4, 2023.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on November 4, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- ASCENSION HEALTH SENIOR CARE5% or greater direct ownership interest · 100% · since 07/01/2014
- SIDHU, SARFRAZOperational/managerial control · not applicable · since 11/01/2018
- ST LOUIS, STEVENOperational/managerial control · not applicable · since 01/23/2025
Questions
When was Franciscan Woods last inspected?
CMS lists April 9, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Franciscan Woods have?
CMS lists 54 health citations since October 5, 2023. CMS also calls these deficiencies.
Has Franciscan Woods been fined?
CMS lists 2 fines in the past three years, $202,745 in total.
What is the CMS star rating of Franciscan Woods?
Its CMS overall star rating is 1 of 5.
Is Franciscan Woods a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.