Franciscan Woods

F 0686 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 Resident R2 was being followed by podiatry as stated by Resident R2's EMR.

Corporate Consultant-G states Resident R2 did not follow podiatry during Resident 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 Resident 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 Resident R2's pressure injuries as she was not working for the facility at that time. Surveyor asked who

she could speak to regarding Resident 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 Resident R2 developing bilateral pressure injuries while at the facility on 11/1/25. Surveyor notified DON-B of the following concerns with Resident R2's facility acquired bilateral heel pressure injuries:Resident 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.Resident R2 returned to the facility on [DATE REDACTED], with no comprehensive skin assessment completed until 2 days later, on 11/9/25.Resident R2's wound care treatment orders were entered on to Resident R2's TAR on 11/11/25 which is 4 days after Resident R2 returned to the hospital.Resident R2's care plan was not updated with facility acquired pressure injuries until 11/10/25.Resident 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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Franciscan Woods

19525 W North Ave Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759

Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or potential for actual harm

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 (Resident R8 and Resident R9) of 4 residents during medication administration. Findings include: On 12/18/25, at 7:54 AM, Surveyor observed LPN-E administer medications to Resident R9. Resident 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 Resident R9 who swallowed the medications whole with water. On 12/18/25, at 8:29 AM, Surveyor observed LPN-E administer medications to Resident R8. Resident 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. Resident R8 overheard LPN-E stabbing the bubble packs from the hallway and yelled out to LPN-E, stating Resident R8 did not want their medications crushed. LPN-E responded to Resident R8 stating she did not have fake nails to open the bubble packs and was not crushing Resident 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 Resident 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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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