Cycle 1
Health 2024-11-14 · Fire 2024-11-14
24 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Brookfield, WI
Franciscan Woods
1-star overall rating with 1-star inspections with $118,144 in total fines with 24 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
19525 W North Ave, Brookfield, WI
(262) 785-1114
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
66
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ascension Living
Operator or chain grouping
Approved since
1993-12-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.78
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.22
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.46
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.01
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.99
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.77
CMS adjusted RN staffing hours
Adjusted total hours
4.38
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,940
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.80
Composite VBP score used to determine payment impact.
Payment multiplier
1.0002
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.35
Baseline 26.23% · Performance 20.85% · Measure score 5.35 · Achievement 1.26 · Improvement 5.35
Healthcare-associated infections
8.79
Baseline 7.63% · Performance 5.21% · Measure score 8.79 · Achievement 8.79 · Improvement 8.7
Total nurse turnover
1.42
Baseline 63.23% · Performance 57.89% · Measure score 1.42 · Achievement 1.42 · Improvement 0.89
Adjusted total nurse staffing
3.16
Baseline 3.73 hours · Performance 3.98 hours · Measure score 3.16 · Achievement 3.16 · Improvement 0.71
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.47% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 182 · Observed rate 9.34% · Lower 95% interval 8.03% |
| Discharge to community | 52.47% |
50.57%
1.9 pts better
|
No Different than the National Rate · Eligible stays 176 · Observed rate 47.73% · Lower 95% interval 45.77% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.66% |
95.27%
2.4 pts better
|
Numerator 125 · Denominator 128 |
| Falls with major injury | 1.56% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 128 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 44 · Denominator 88 |
| Discharge mobility score | 40.91% |
50.94%
10 pts worse
|
Numerator 36 · Denominator 88 |
| Pressure ulcers or injuries, new or worsened | 0.79% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 127 · Adjusted rate 0.93% |
| Healthcare-associated infections requiring hospitalization | 5.21% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 2.44% · Lower 95% interval 2.91% |
| Staff COVID-19 vaccination coverage | 20.18% |
8.2%
12 pts better
|
Numerator 23 · Denominator 114 |
| Staff flu vaccination coverage | 84.25% |
42%
42.2 pts better
|
Numerator 123 · Denominator 146 |
| Discharge function score | 57.95% |
56.45%
1.5 pts better
|
Numerator 51 · Denominator 88 |
| Transfer of health information to provider | 92.11% |
95.95%
3.8 pts worse
|
Numerator 35 · Denominator 38 |
| Transfer of health information to patient | 94.2% |
96.28%
2.1 pts worse
|
Numerator 65 · Denominator 69 |
| Resident COVID-19 vaccinations up to date | 36.76% |
25.2%
11.6 pts better
|
Numerator 25 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
95.7%
6.2 pts worse
|
93.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.9% · Q2 86.0% · Q3 88.5% · Q4 88.2% · 4Q avg 89.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.5% |
95.0%
0.5 pts better
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.2%
2.3 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
5.0%
4.1 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
4.9%
0.2 pts worse
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 4.9% · Q4 14.3% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
16.6%
3.9 pts worse
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 22.5% · Q3 18.6% · Q4 20.0% · 4Q avg 20.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.9% |
16.7%
1.2 pts worse
|
16.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 16.2% · Q3 15.8% · Q4 19.4% · 4Q avg 17.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.1% |
21.1%
8 pts worse
|
16.3%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.0% |
17.3%
4.7 pts worse
|
14.9%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 23.7% · Q3 20.0% · Q4 24.2% · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
3.0%
1.7 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.8% · Q3 0.0% · Q4 2.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
25.5%
1.8 pts better
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 26.0% · Q3 28.0% · Q4 19.1% · 4Q avg 23.7% |
| Percentage of long-stay residents with pressure ulcers | 10.3% |
5.5%
4.8 pts worse
|
5.1%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 13.6% · Q3 10.4% · Q4 9.0% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.0% |
86.8%
1.2 pts better
|
81.7%
6.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 88.6% · Q3 85.1% · Q4 91.4% · 4Q avg 88.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.1% |
15.0%
3.1 pts worse
|
12.0%
6.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.1% · Observed 17.1% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.2% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.8% |
82.2%
3.6 pts better
|
79.7%
6.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
22.7%
1.4 pts worse
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 22.9% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-05 · Fire 2023-10-05
12 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-07-18 · Fire 2022-07-18
16 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-08
F · Potential for more than minimal harm
2024-11-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-08
F · Potential for more than minimal harm
2024-11-14
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2025-01-08
F · Potential for more than minimal harm
2024-11-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Not marked corrected
D · Potential for more than minimal harm
2024-11-14
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-11-14
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-11-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-11-14
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-11-14
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2025-01-08
F · Potential for more than minimal harm
2023-10-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-04
E · Potential for more than minimal harm
2023-10-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-04
D · Potential for more than minimal harm
2023-10-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-04
F · Potential for more than minimal harm
2022-07-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-16
E · Potential for more than minimal harm
2022-07-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-16
Inspection history
Recent health citations
G · Actual harm
2025-12-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-03
D · Potential for more than minimal harm
2025-12-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-02-03
D · Potential for more than minimal harm
2025-12-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-05-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-02
G · Actual harm
2025-03-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-18
G · Actual harm
2025-03-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-02
E · Potential for more than minimal harm
2025-03-20
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-23
E · Potential for more than minimal harm
2025-03-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-20
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-20
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-04-23
G · Actual harm
2025-02-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-02-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-14
D · Potential for more than minimal harm
2024-12-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-23
G · Actual harm
2024-11-14
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-11-14
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-14
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-14
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-12-10
C · Minimal harm
2024-11-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-04-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-05
E · Potential for more than minimal harm
2023-10-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-04
E · Potential for more than minimal harm
2023-10-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-04
D · Potential for more than minimal harm
2023-10-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-04
D · Potential for more than minimal harm
2023-10-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-04
D · Potential for more than minimal harm
2023-10-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-04
D · Potential for more than minimal harm
2023-10-05
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-11-04
C · Minimal harm
2023-10-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-11-04
D · Potential for more than minimal harm
2023-03-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-04-06
G · Actual harm
2022-07-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-16
E · Potential for more than minimal harm
2022-07-18
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-07-18
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-07-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-07-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-07-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-07-18
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-07-18
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-07-18
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-07-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-07-18
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-07-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-07-18
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-07-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-16
Penalties and ownership
What sits behind the stars
$118,144
2025-02-11
Fine
Fine · fine $118,144
Fine
$0
2025-02-11
Payment Denial
Payment Denial · denial start 2025-03-13 · 97 days
97 day denial
$0
2024-11-14
Payment Denial
Payment Denial · denial start 2024-12-14 · 31 days
31 day denial
Ownership
Ascension Health Senior Care
5% Or Greater Direct Ownership Interest · Organization
Musgrave, Lisa
Corporate Director · Individual
Shadbolt, Erin
Corporate Director · Individual
Sidhu, Sarfraz
Operational/Managerial Control · Individual
Smoot, Kenneth
Corporate Director · Individual
St Louis, Steven
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Complete Care at Care Age
Brookfield, WI
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Aria Of Brookfield
Brookfield, WI
1-star overall rating with 1-star inspections with Special Focus status with $453,512 in total fines with 27 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Congregational Home, Inc
Brookfield, WI
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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