Franciscan Woods
Franciscan Woods in BROOKFIELD, WI — inspection on December 22, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
was doing wound care.
Surveyor requested to speak with that nurse once NHA-A found out who was doing wound care rounds. On 12/17/25, at 2:44 PM, at end of day meeting, Surveyor asked if the facility knew who was performing wound care rounds.
Corporate Consultant- G states Nurse-I who was an agency nurse was going to be doing wound rounds. NHA-A states Nurse-I was not available at the time for interview.
Surveyor requested to speak with Nurse-I when available.
Surveyor then asked what the process is for skin assessments and wound care treatments when a resident returns from the hospital.
Corporate Consultant-G states, the resident is seen by the wound care physician at the next scheduled wound care rounds, the admitting nurse will perform a comprehensive skin assessment and enter in treatment orders with the wound care nurse.
Corporate Consultant-G states the comprehensive skin assessment includes staging, measurements, and wound bed description that is to be completed the same day of admission/readmission.
Surveyor asked if R2 was being followed by podiatry as stated by R2's EMR.
Corporate Consultant-G states R2 did not follow podiatry during R2's admission at the facility from 9/12/25 11/21/25. On 12/18/25, at 10:54 AM, Surveyor interviewed Director of Nursing (DON)-B who states she was not at the facility at the time of discovery of R2's facility acquired bilateral heel pressure injuries on 11/1/25.
DON-B stated the facility had a wound care nurse who previously worked at the facility and is no longer at the facility. DON-B then stated that is on her for these facility acquired pressure injuries and DON-B can't speak upon R2's pressure injuries as she was not working for the facility at that time.
Surveyor asked who she could speak to regarding R2's facility acquired pressure injuries and DON-B stated she was not sure and directed Surveyor to Nursing Home Administrator (NHA)-A.
Surveyor notified DON-B of concerns with R2 developing bilateral pressure injuries while at the facility on 11/1/25.
Surveyor notified DON-B of the following concerns with R2's facility acquired bilateral heel pressure injuries:R2 is a diabetic with no documentation of daily diabetic foot checks being performed.Last documented skin assessment performed on 10/20/25, with new discovery of bilateral heel pressure injuries with eschar present on 11/1/25.R2 returned to the facility on [DATE], with no comprehensive skin assessment completed until 2 days later, on 11/9/25.R2's wound care treatment orders were entered on to R2's TAR on 11/11/25 which is 4 days after R2 returned to the hospital.R2's care plan was not updated with facility acquired pressure injuries until 11/10/25.R2 was assessed with being at risk for pressure injuries with no documentation of person-centered interventions of turning and repositioning to prevent pressure injuries.DON-B acknowledged these concerns.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Franciscan Woods
19525 W North Ave Brookfield, WI 53045
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview and record review the facility did not ensure the medication error rate was below 5% during medication pass.
Surveyor observed 20 out of 32 opportunities with a medication error rate of 62.5%. On 12/18/25, Surveyor observed Licensed Practical Nurse (LPN)- E stab 20 bubble packs with a pen for 2 (R8 and R9) of 4 residents during medication administration.
Findings include: On 12/18/25, at 7:54 AM, Surveyor observed LPN-E administer medications to R9. R9 was administered 8 medication that included:Amlodipine 5 mg tabletCertravite (Multivitamin) 1 tabletFolic Acid 1 mg tabletHydrochlorothiazide 12.5 mg tabletTurmeric 500 mg tabletVitamin B complex 1 tabletThiamine 100 mg tabletVitamin C 500 mg tabletSurveyor observed each medication to be individually wrapped in a bubble packet and observed LPN-E lay out all 8 bubble packs on top of the medication cart and press the button on her pen to expose the ballpoint on the pen and stab each individual packet with the open ball point pen. LPN-E then placed each bubble pack over a medicine cup to push out the tablet into the medication cup. LPN-E then walked over to R9 who swallowed the medications whole with water. On 12/18/25, at 8:29 AM, Surveyor observed LPN-E administer medications to R8. R8 was administered 12 medications that included:Tamsulosin 0.4 mg (2 tablets)Losartan 50 mg tabletMemantine 5 mg tabletMetoprolol Extended Release (ER) 25 mg tabletThiamine 100 mg tabletVitamin K with D3 100 mcg tabletAspirin 81 mg tabletChlorthalidone 25 mg tabletCoQ10 100 mg tabletFolic Acid 1 mg tabletGabapentin 300 mg tabletGlimepiride 2 mg tabletSurveyor observed each medication to be individually wrapped in a bubble packet and observed LPN-E lay out all 12 bubble packs on top of the medication cart and press the button on her pen to expose the ballpoint on the pen and stab each individual packet with the open ball point pen. R8 overheard LPN-E stabbing the bubble packs from the hallway and yelled out to LPN-E, stating R8 did not want their medications crushed. LPN-E responded to R8 stating she did not have fake nails to open the bubble packs and was not crushing R8's medications.
LPN-E then placed each bubble pack over a medicine cup to push out the tablet into the medication cup.
LPN-E then walked over to R8 who swallowed the medications whole with water. On 12/18/25, at 10:54 AM, Surveyor notified Director of Nursing (DON)-B of concerns with performing observations of medication pass with 32 opportunities.
Surveyor notified DON-B of Surveyor observing LPN-E stabbing 20 bubble packs open with a ball point pen exposed to break medication bubble packs which makes a 62.5% medication error rate with 20 out of 32 opportunities. DON-B acknowledged the concerns.
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