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Franciscan Woods

πŸ“ 19525 W North Ave, Brookfield, WI 53045 πŸ“ž (262) 785-1114 πŸ›οΈ 110 beds

Inspection History Overview

Detailed Inspection Reports

Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.

March 20, 2025 Complaint Investigation

Fines and Penalties by Year

2021 2 penalties totaling $86,314

$86,314
Apr 7, 2021

Fine

$0
Apr 7, 2021

Payment Denial

2019 3 penalties totaling $35,955

$9,955
Dec 17, 2019

Fine

$17,043
May 22, 2019

Fine

$8,957
May 22, 2019

Fine

2018 1 penalties totaling $10,689

$10,689
Jun 13, 2018

Fine

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Health Violations by Year

2025 11 violations

Tag 0585 D Mar 20, 2025

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.

βœ“ Corrected: Apr 23, 2025
Tag 0607 E Mar 20, 2025

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

βœ“ Corrected: Apr 23, 2025
Tag 0609 D Mar 20, 2025

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

βœ“ Corrected: Apr 23, 2025
Tag 0610 E Mar 20, 2025

Respond appropriately to all alleged violations.

βœ“ Corrected: Apr 23, 2025
Tag 0686 G Mar 20, 2025

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

βœ“ Corrected: Jun 18, 2025
Tag 0692 G Mar 20, 2025

Provide enough food/fluids to maintain a resident's health.

βœ“ Corrected: Apr 23, 2025
Tag 0700 D Mar 20, 2025

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.

βœ“ Corrected: Apr 23, 2025
Tag 0880 F Mar 20, 2025

Provide and implement an infection prevention and control program.

βœ“ Corrected: Jun 2, 2025
Tag 0684 D Feb 11, 2025

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

βœ“ Corrected: Mar 12, 2025
Tag 0686 G Feb 11, 2025

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

βœ“ Corrected: Jun 18, 2025
Tag 0757 D Jan 14, 2025

Ensure each resident’s drug regimen must be free from unnecessary drugs.

βœ“ Corrected: Feb 14, 2025

2024 1 violations

Tag 0842 E Apr 5, 2024

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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2023 11 violations

Tag 0607 C Oct 5, 2023

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

βœ“ Corrected: Nov 4, 2023
Tag 0609 E Oct 5, 2023

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

βœ“ Corrected: Nov 4, 2023
Tag 0610 E Oct 5, 2023

Respond appropriately to all alleged violations.

βœ“ Corrected: Nov 4, 2023
Tag 0684 D Oct 5, 2023

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

βœ“ Corrected: Nov 4, 2023
Tag 0686 D Oct 5, 2023

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

βœ“ Corrected: Nov 4, 2023
Tag 0755 D Oct 5, 2023

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

βœ“ Corrected: Nov 4, 2023
Tag 0758 D Oct 5, 2023

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.

βœ“ Corrected: Nov 4, 2023
Tag 0580 D Mar 7, 2023

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

βœ“ Corrected: Apr 13, 2023
Tag 0609 D Jan 17, 2023

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

βœ“ Corrected: Feb 17, 2023
Tag 0610 D Jan 17, 2023

Respond appropriately to all alleged violations.

βœ“ Corrected: Feb 17, 2023
Tag 0755 D Jan 17, 2023

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

βœ“ Corrected: Feb 17, 2023

2022 15 violations

Tag 0582 D Jul 18, 2022

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

βœ“ Corrected: Aug 16, 2022
Tag 0607 E Jul 18, 2022

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

βœ“ Corrected: Aug 16, 2022
Tag 0609 D Jul 18, 2022

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

βœ“ Corrected: Aug 16, 2022
Tag 0610 D Jul 18, 2022

Respond appropriately to all alleged violations.

βœ“ Corrected: Aug 16, 2022
Tag 0623 D Jul 18, 2022

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

βœ“ Corrected: Aug 16, 2022
Tag 0625 D Jul 18, 2022

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

βœ“ Corrected: Aug 16, 2022
Tag 0660 D Jul 18, 2022

Plan the resident's discharge to meet the resident's goals and needs.

βœ“ Corrected: Aug 16, 2022
Tag 0661 D Jul 18, 2022

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

βœ“ Corrected: Aug 16, 2022
Tag 0684 G Jul 18, 2022

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

βœ“ Corrected: Aug 16, 2022
Tag 0695 D Jul 18, 2022

Provide safe and appropriate respiratory care for a resident when needed.

βœ“ Corrected: Aug 16, 2022
Tag 0740 D Jul 18, 2022

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

βœ“ Corrected: Aug 16, 2022
Tag 0756 D Jul 18, 2022

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

βœ“ Corrected: Aug 16, 2022
Tag 0758 D Jul 18, 2022

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.

βœ“ Corrected: Aug 16, 2022
Tag 0812 D Jul 18, 2022

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

βœ“ Corrected: Aug 16, 2022
Tag 0880 D Jul 18, 2022

Provide and implement an infection prevention and control program.

βœ“ Corrected: Aug 16, 2022
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2021 7 violations

Tag 0689 D Oct 14, 2021

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

βœ“ Corrected: Nov 13, 2021
Tag 0883 D Sep 30, 2021

Develop and implement policies and procedures for flu and pneumonia vaccinations.

βœ“ Corrected: Oct 30, 2021
Tag 0887 D Sep 30, 2021

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.

βœ“ Corrected: Oct 30, 2021
Tag 0684 D Apr 7, 2021

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

βœ“ Corrected: May 13, 2021
Tag 0686 G Apr 7, 2021

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

βœ“ Corrected: May 19, 2021
Tag 0804 E Apr 7, 2021

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

βœ“ Corrected: May 13, 2021
Tag 0880 F Apr 7, 2021

Provide and implement an infection prevention and control program.

βœ“ Corrected: May 13, 2021

2020 1 violations

Tag 0880 E May 14, 2020

Provide and implement an infection prevention and control program.

βœ“ Corrected: Jun 5, 2020
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2019 11 violations

Tag 0607 F Dec 17, 2019

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

βœ“ Corrected: Jan 10, 2020
Tag 0689 G Dec 17, 2019

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

βœ“ Corrected: Jan 10, 2020
Tag 0726 D Dec 17, 2019

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

βœ“ Corrected: Jan 10, 2020
Tag 0604 D May 22, 2019

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

βœ“ Corrected: Jul 3, 2019
Tag 0607 D May 22, 2019

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

βœ“ Corrected: Jul 3, 2019
Tag 0610 D May 22, 2019

Respond appropriately to all alleged violations.

βœ“ Corrected: Jul 3, 2019
Tag 0686 G May 22, 2019

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

βœ“ Corrected: Jul 26, 2019
Tag 0757 D May 22, 2019

Ensure each resident’s drug regimen must be free from unnecessary drugs.

βœ“ Corrected: Jul 3, 2019
Tag 0759 D May 22, 2019

Ensure medication error rates are not 5 percent or greater.

βœ“ Corrected: Jul 3, 2019
Tag 0880 D May 22, 2019

Provide and implement an infection prevention and control program.

βœ“ Corrected: Jul 3, 2019
Tag 0920 D May 22, 2019

Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.

βœ“ Corrected: Jul 3, 2019

2018 5 violations

Tag 0550 E Jun 13, 2018

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

βœ“ Corrected: Jun 30, 2018
Tag 0686 G Jun 13, 2018

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

βœ“ Corrected: Jun 30, 2018
Tag 0758 D Jun 13, 2018

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.

βœ“ Corrected: Jun 30, 2018
Tag 0812 F Jun 13, 2018

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

βœ“ Corrected: Jun 30, 2018
Tag 0880 D Jun 13, 2018

Provide and implement an infection prevention and control program.

βœ“ Corrected: Jun 30, 2018
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2017 9 violations

Tag 0164 E Apr 6, 2017

Keep residents' personal and medical records private and confidential.

βœ“ Corrected: May 5, 2017
Tag 0246 D Apr 6, 2017

Reasonably accommodate the needs and preferences of each resident.

βœ“ Corrected: May 5, 2017
Tag 0309 D Apr 6, 2017

Provide necessary care and services to maintain or improve the highest well being of each resident .

βœ“ Corrected: May 5, 2017
Tag 0312 E Apr 6, 2017

Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.

βœ“ Corrected: May 5, 2017
Tag 0314 D Apr 6, 2017

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

βœ“ Corrected: May 5, 2017
Tag 0334 D Apr 6, 2017

Develop policies and procedures for influenza and pneumococcal immunizations.

βœ“ Corrected: May 5, 2017
Tag 0371 J Apr 6, 2017

Store, cook, and serve food in a safe and clean way.

βœ“ Corrected: May 5, 2017
Tag 0441 D Apr 6, 2017

Have a program that investigates, controls and keeps infection from spreading.

βœ“ Corrected: May 5, 2017
Tag 0465 F Apr 6, 2017

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

βœ“ Corrected: May 5, 2017
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