Chi Franciscan Villa
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
On 11/13/25, at 11:03 AM, Surveyor interviewed Resident R2 in Resident R2's room. Resident R2 stated Resident R2 had a fall about 2 weeks ago when trying to get onto the commode from the wheelchair. Surveyor observed Resident R2 sitting on the edge of
the bed with Resident R2's feet resting on a folded-up sheet on the floor. Resident R2 stated Resident R2's family brought in a door mat and placed the folded-up sheet on top of it to prevent Resident R2 from falling. Surveyor did not observe any signage posted in Resident R2's room reminding Resident R2 to wait for assistance. Resident R2 stated no signs were ever put up in Resident R2's room.
On 11/13/25, at 11:33 AM, Surveyor interviewed certified nursing assistant (CNA)-D regarding trip hazards.
CNA-D stated online training the facility provides touches on trip hazards. Surveyor asked if the folded-up sheet in Resident R2's room would be considered a trip hazard, and CNA-D replied CNA-D would consider that a trip hazard, but Resident R2 specifically requested it to be there because Resident R2's legs are currently leaking and Resident R2 does not want the floor to get wet. Surveyor asked what the process is if a resident makes a request that is not considered safe, and CNA-D replied CNA-D was not sure, but the nurse on duty would know the process.
On 11/13/25, at 11:50 AM, Surveyor interviewed Unit Manager-F regarding the process if a resident makes
a request that is not considered safe. Unit Manager-F stated staff would try to have a conversation with the resident and educate them on safe practices. Unit Manager-F stated a risk versus benefits could be completed, and the resident's care plan could be updated to include the request. Surveyor asked Unit Manager-F if a folded-up sheet on the floor would be considered a trip hazard, and Unit Manager-F replied yes, that is a trip hazard. Unit Manager-F was not aware the folded-up sheet was in Resident R2's room and stated Unit Manager-F would educate Resident R2 and remove the sheet.
Surveyor reviewed Resident R2's EHR and did not locate any risk versus benefits or care plan revisions regarding
the folded-up sheet in Resident R2's room.
On 11/13/25, at 2:45 PM, Surveyor interviewed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A regarding fall risk evaluations. DON-B stated a fall risk evaluation would be completed when triggered by the MDS coordinator, after a fall, or if there is a change in condition. DON-B stated the fall risk evaluation is typically completed by the nurse on the floor or the MDS coordinator.
Surveyor shared concern with DON-B and NHA-A that Surveyor observed Resident R2's feet resting on a folded-up blanket and that Surveyor did not observe any signage in Resident R2's room reminding Resident R2 to wait for assistance per Resident R2's care plan. DON-B agreed that the folded-up blanket would be a trip hazard, and staff has talked with Resident R2's family in the past regarding trip hazards, but DON-B would follow up.
On 11/13/25, at 3:08 PM, Surveyor interviewed MDS coordinator-G via phone call. MDS coordinator-G stated fall risk evaluations are completed by MDS coordinator-G only on a quarterly basis when it gets triggered in the EHR that a quarterly MDS assessment is due. MDS coordinator-G confirmed that MDS coordinator-G completed the fall risk evaluation for Resident R2 dated 10/9/25. Surveyor asked why there was no response for question 2 under the medications section on this assessment. MDS coordinator-G responded MDS coordinator-G must have accidentally clicked to the next page, and the fall risk evaluation was not completed correctly. MDS coordinator-G stated question 2 under the medications section should have been marked as c. Takes 3-4 of these medications (or medication classes) currently and/or within last 7 days which would have resulted in a higher fall risk score.
On 11/13/25, at 3:34 PM, Surveyor shared concern with NHA-A and DON-B that the fall risk evaluation for Resident R2 dated 10/9/25 was not completed accurately. No additional information was provided as to why Resident R2's fall interventions were not in place to prevent future falls or why an accurate fall risk evaluation was not completed for Resident R2.
FORM CMS-2567 (02/99) Previous Versions Obsolete
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CHI FRANCISCAN VILLA in SOUTH MILWAUKEE, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SOUTH MILWAUKEE, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CHI FRANCISCAN VILLA or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.