Franciscan Woods

Nursing Home · Brookfield, WI

CMS overall rating 1/5 Non profit - Corporation

CMS certification number525528

Contact & location

19525 W North Ave
Brookfield, WI 53045
Waukesha County
Phone
(262) 785-1114
ZIP code
53045 – all care providers

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Facility details

Certified beds
110
Residents per day
55.3 (50% occupied)
Ownership
Non profit - Corporation
Legal name
Wheaton Franciscan Healthcare Terrace at ST. Francis, INC.
Chain
Ascension Living (12 facilities, avg 2.8★)
Medicare certified since
December 30, 1993
Participates in
Medicare and Medicaid
Council
Resident council

CMS star ratings

Overall★★★★★ 1/5
State avg 3.0
Health inspections★★★★★ 1/5
State avg 2.8
Staffing★★★★★ 4/5
State avg 3.6
Quality measures★★★★★ 2/5
State avg 3.0
Long-stay quality★★★★★ 2/5
Short-stay quality★★★★★ 3/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
4.39 (state 4.21 · U.S. 3.86)
Registered nurses (RN)
0.95 (state 0.99 · U.S. 0.69)
Licensed practical nurses
1.25 (state 0.64 · U.S. 0.86)
Nurse aides
2.19 (state 2.58 · U.S. 2.32)
Weekend total
3.67 (state 3.77 · U.S. 3.42)
Nursing staff turnover
76.0 (state 46.9 · U.S. 45.8)%
RN turnover
27.3 (state 39.7 · U.S. 42.9)%
Administrators who left
2 in the last year

Inspections

Last standard inspection
April 9, 2026
Health deficiencies (last cycle)
17.0 (state 9.5 · U.S. 9.3)
From complaints
3
Citations on record (3 years)
50 health · 17 fire safety · includes actual harm
DateCitationSeverityStatus
2026-04-09 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2026-05-08
2026-04-09 Implement a program that monitors antibiotic use.
F0881 · Infection Control Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2026-05-08
2026-04-09 Ensure that residents are fully informed and understand their health status, care and treatments.
F0552 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 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.
F0628 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 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.
F0676 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-05-08
2026-04-09 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-05-08
2026-04-09 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 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.
F0689 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 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.
F0693 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 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.
F0755 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 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.
F0761 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 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.
F0849 · Administration Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-05-08
2026-04-09 Develop and implement policies and procedures for flu and pneumonia vaccinations.
F0883 · Infection Control Deficiencies		 D
No actual harm, potential for more than minimal harm		 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.
F0887 · Infection Control Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-05-08
2025-12-22 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2026-02-03
2025-12-22 Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 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.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 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.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 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.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-06-02
2025-05-06 Ensure each resident’s drug regimen must be free from unnecessary drugs.
F0757 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-06-02
2025-03-20 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2025-06-18
2025-03-20 Provide enough food/fluids to maintain a resident's health.
F0692 · Quality of Life and Care Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2025-04-23
2025-03-20 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 F
No actual harm, potential for more than minimal harm		 Corrected 2025-06-02
2025-03-20 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-04-23
2025-03-20 Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 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.
F0585 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-23
2025-03-20 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 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.
F0700 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-23
2025-02-11 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2025-06-18
2025-02-11 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-12
2025-01-14 Ensure each resident’s drug regimen must be free from unnecessary drugs.
F0757 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 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.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 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.
F0693 · Quality of Life and Care Deficiencies · complaint inspection		 G
Actual harm		 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.
F0725 · Nursing and Physician Services Deficiencies · complaint inspection		 F
No actual harm, potential for more than minimal harm		 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.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-12-10
2024-11-14 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 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.
F0580 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 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.
F0585 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 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.
F0623 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-12-10
2024-11-14 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 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.
F0758 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-12-10
2024-11-14 Post nurse staffing information every day.
F0732 · Nursing and Physician Services Deficiencies		 C
No actual harm, potential for minimal harm		 Corrected 2024-12-10
2024-04-05 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-05-05
2023-10-05 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-11-04
2023-10-05 Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-11-04
2023-10-05 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-11-04
2023-10-05 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 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.
F0755 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 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.
F0758 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-11-04
2023-10-05 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 C
No actual harm, potential for minimal harm		 Corrected 2023-11-04

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

3 penalties in the last three years, including $120,905 in fines.

DateTypeAmount
2025-02-11Payment Denial97 days payment denial
2025-02-11Fine$120,905
2024-11-14Payment Denial31 days payment denial

Ownership & management

NameRoleSince
Ascension Health Senior Care (organization)5%+ Direct Ownership Interest · 100%
Ascension Health Senior Care (organization)Administrator · NOT APPLICABLE
Fast Pace Medical Staffing INC (organization)Administrator · NOT APPLICABLE
Favorite Healthcare Staffing LLC (organization)Administrator · NOT APPLICABLE
Health Dimensions Consulting INC (organization)Administrator · NOT APPLICABLE
House Healthcare Solutions LLC (organization)Administrator · NOT APPLICABLE
Medical Solutions LLC (organization)Administrator · NOT APPLICABLE
Medical Staffing Solutions LLC (organization)Administrator · NOT APPLICABLE
Michael Porter (organization)Administrator · NOT APPLICABLE
Musgrave, Lisa (individual)Administrator · NOT APPLICABLE
Nursing Centers, INC. (organization)Administrator · NOT APPLICABLE
Personnel Specialists LLC (organization)Administrator · NOT APPLICABLE
PRN Health Services, INC. (organization)Administrator · NOT APPLICABLE
Prolink Healthcare LLC (organization)Administrator · NOT APPLICABLE
Shadbolt, Erin (individual)Administrator · NOT APPLICABLE
Sidhu, Sarfraz (individual)Administrator · NOT APPLICABLE
Smoot, Kenneth (individual)Administrator · NOT APPLICABLE
ST Louis, Steven (individual)Administrator · NOT APPLICABLE
Staff One, LTD. (organization)Administrator · NOT APPLICABLE
Musgrave, Lisa (individual)Corporate Director · NOT APPLICABLE
Shadbolt, Erin (individual)Corporate Director · NOT APPLICABLE
Smoot, Kenneth (individual)Corporate Director · NOT APPLICABLE
Sidhu, Sarfraz (individual)Operational/managerial Control · NOT APPLICABLE
ST Louis, Steven (individual)Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of Franciscan Woods?

Franciscan Woods has a 1-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.0-star average in Wisconsin.

How many beds does Franciscan Woods have?

It has 110 certified beds and cares for about 55 residents per day.

Has Franciscan Woods been fined?

Yes. CMS lists 3 penalties totaling $120,905 in the last three years.

Who owns Franciscan Woods?

It is part of Ascension Living and is classified as non profit - corporation. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Franciscan Woods?

(262) 785-1114. The facility is located at 19525 W North Ave, Brookfield, WI 53045.

Other nursing homes in Brookfield

Compare all nursing homes in Brookfield, WI →

Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.