Public Record
Franciscan Woods
From CMS
Facility profile
- CMS overall rating
- 2 / 5
- Certified beds
- 110
- Avg. residents per day
- 63.7
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 66
- Inspections on file
- 15
- Last inspection
- 2025-12-22
*CMS
*CMS
*CMS
Citations
66 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.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 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.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0692Seriousactual harm
Provide enough food/fluids to maintain a resident's health.
- 0700Generalpotential for harm
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.
- 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.
- 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.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 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.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0015Generalpotential for harm
Address subsistence needs for staff and patients.
- 0013Generalpotential for harm
Develop Emergency Preparedness policies and procedures.
- 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.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 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.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0693Seriousactual harm
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.
- 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.
- 0925Generalpotential for harm
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
- 0751Generalpotential for harm
Have restrictions on the use of flammable curtains.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 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.
- 0607Generalno actual harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 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.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 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.
- 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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0661Generalpotential for harm
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
- 0660Generalpotential for harm
Plan the resident's discharge to meet the resident's goals and needs.
- 0625Generalpotential for harm
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.
- 0623Generalpotential for 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.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0582Generalpotential for harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0684Seriousactual harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 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.
- 0740Generalpotential for harm
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
FAQ
Questions and answers
- What is Franciscan Woods?
- Franciscan Woods is a Medicare- and Medicaid-certified nursing home in Brookfield, WI, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 525528.
- What is the CMS rating for Franciscan Woods?
- Franciscan Woods has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Franciscan Woods have?
- Franciscan Woods is certified for 110 beds. It serves an average of 63.7 residents per day.
- How many citations does Franciscan Woods have?
- Franciscan Woods has 66 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Franciscan Woods last inspected?
- Franciscan Woods was last inspected on December 22, 2025. 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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