CHI FRANCISCAN VILLA
Grade F — 51/100 composite score
CMS Star Ratings
Certified Beds
90
Ownership
Non profit - Corporation
Total Fines
$337,358
Last Survey
N/A
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Staffing Hours & Turnover
Hours per Resident per Day (PBJ)
Turnover Rates
Ownership
SYLVANIA FRANCISCAN HEALTH
100%
COMMONSPIRIT HEALTH
100%
MELFI, MITCH
RICHARDSON MBANU, TERIKA
IFFLAND, ALISA
LIPSEY, PRENTICE
REHMER, HEATHER
GULOCK, MICHAEL
Penalties & Fines (5)
| Date | Type | Description | Amount |
|---|---|---|---|
| Feb 20, 2025 | Fine | — | $44,532 |
| Nov 8, 2024 | Fine | — | $187,380 |
| Dec 5, 2023 | Fine | — | $15,593 |
| Dec 5, 2023 | Payment Denial | — | — |
| Jul 12, 2023 | Fine | — | $89,853 |
Health Inspection Deficiencies (68)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
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.
Nutrition and Dietary Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies
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.
Resident Rights Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies
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.
Pharmacy Service Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Administration Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Administration Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Nursing and Physician Services Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Administration Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
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.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies
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.
Pharmacy Service Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Perform COVID19 testing on residents and staff.
Infection Control Deficiencies
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Frequently Asked Questions
What is the CareGrader rating for CHI FRANCISCAN VILLA?
CHI FRANCISCAN VILLA in SOUTH MILWAUKEE, Wisconsin has a CareGrader grade of F (Poor), with a composite score of 50.5 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.
What is the CMS star rating for CHI FRANCISCAN VILLA?
CHI FRANCISCAN VILLA has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.
How many health deficiencies does CHI FRANCISCAN VILLA have?
CHI FRANCISCAN VILLA has 68 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.
Has CHI FRANCISCAN VILLA been fined?
Yes. CHI FRANCISCAN VILLA has $337,358 in total fines from CMS enforcement actions across 5 penalties.
How many beds does CHI FRANCISCAN VILLA have?
CHI FRANCISCAN VILLA has 90 certified beds with approximately 85 current residents (94% occupancy). The facility is located at 3601 S CHICAGO AVE, SOUTH MILWAUKEE, Wisconsin 53172. It is a non profit - corporation facility.
Data Disclaimer
Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.