Public Record
Chi Franciscan Villa
From CMS
Facility profile
- CMS overall rating
- 1 / 5
- Certified beds
- 90
- Avg. residents per day
- 84.3
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 120
- Inspections on file
- 17
- Last inspection
- 2026-02-18
*CMS
*CMS
*CMS
Citations
120 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0557Generalpotential for harm
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- 0585Generalpotential for harm
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.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0676Generalpotential for harm
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- 0573Generalpotential for harm
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0602Generalpotential for harm
Protect each resident from the wrongful use of the resident's belongings or money.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0801Generalpotential for harm
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0354Generalpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0346Generalpotential for harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0331Generalpotential for harm
Construct fire resistant interior walls.
- 0293Generalpotential for harm
Have properly located and lighted "Exit" signs.
- 0222Generalpotential for harm
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.
- 0039Generalpotential for harm
Conduct testing and exercise requirements.
- 0025Generalpotential for harm
Create arrangements with other facilities to receive patients.
- 0020Generalpotential for harm
Establish policies and procedures including evacuation.
- 0006Generalpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0600Seriousimmediate jeopardy
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0578Generalpotential for harm
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0761Generalpotential for harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0851Generalpotential for harm
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
- 0111Generalpotential for harm
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
- 0291Generalno actual harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0345Generalno actual harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0362Generalpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0711Generalpotential for harm
Provide a written emergency evacuation plan.
- 0914Generalpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0918Generalno actual harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0684Seriousimmediate jeopardy
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0949Generalpotential for harm
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
- 0947Generalpotential for harm
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- 0944Generalpotential for harm
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0600Seriousimmediate jeopardy
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0342Generalpotential for harm
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0354Generalpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0361Generalpotential for harm
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0919Generalpotential for harm
Meet requirements for the use of electrical equipment.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0037Generalpotential for harm
Establish staff and initial training requirements.
- 0225Generalpotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0232Generalpotential for harm
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
- 0311Generalpotential for harm
Have an enclosure around a vertical opening shaft.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0684Seriousactual harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0688Generalpotential for harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0758Generalpotential for harm
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.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0886Generalpotential for harm
Perform COVID19 testing on residents and staff.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0623Generalno actual harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
FAQ
Questions and answers
- What is Chi Franciscan Villa?
- Chi Franciscan Villa is a Medicare- and Medicaid-certified nursing home in South Milwaukee, WI, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 525526.
- What is the CMS rating for Chi Franciscan Villa?
- Chi Franciscan Villa has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Chi Franciscan Villa have?
- Chi Franciscan Villa is certified for 90 beds. It serves an average of 84.3 residents per day.
- How many citations does Chi Franciscan Villa have?
- Chi Franciscan Villa has 120 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Chi Franciscan Villa last inspected?
- Chi Franciscan Villa was last inspected on February 18, 2026. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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