CHI FRANCISCAN VILLA
Open-data reference.
CHI FRANCISCAN VILLA is a non profit - corporation facility in SOUTH MILWAUKEE, WI with 90 certified beds and a 1-star overall CMS rating. The facility has 50 deficiency records on file. Total penalties: $272K.
3601 S CHICAGO AVE, SOUTH MILWAUKEE, WI 53172
Phone: 4147644100
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 525526
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 90
- Residents
- 86
- In Hospital
- No
- County
- Milwaukee
- Last Inspection
- Feb 20, 2025
Staffing Data
- RN Hours
- 0.54 (nat'l avg: 0.68)
- LPN Hours
- 0.53
- CNA Hours
- 2.49
- Total Nursing Hours
- 3.56 (nat'l avg: 3.89)
- PT Hours
- 0.06
What the CMS Record Reveals About CHI FRANCISCAN VILLA
CHI FRANCISCAN VILLA operates 90 certified beds in SOUTH MILWAUKEE, WI with approximately 86 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (1★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, of which 7 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 4 penalties totaling $272K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.56 total nursing hours per resident day (national average 3.89), with RN coverage at 0.54 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, CHI FRANCISCAN VILLA falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Category: Resident Rights Deficiencies
Corrected: Jan 26, 2026
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 5, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 5, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 5, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Dec 5, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 12, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 17, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 17, 2025
Protect each resident from the wrongful use of the resident's belongings or money.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 6, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 30, 2025
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Jun 30, 2025
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 30, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 30, 2025
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 30, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 28, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 28, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 20, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 28, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 28, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 28, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Nov 20, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Nov 20, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jul 5, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 5, 2024
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Category: Administration Deficiencies
Corrected: Jan 2, 2024
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Jan 2, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 2, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 2, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 2, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jan 2, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jan 2, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Jan 2, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jan 2, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Jan 2, 2024
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Jan 2, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 2, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Jan 2, 2024
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Jan 2, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 15, 2023
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Category: Administration Deficiencies
Corrected: Aug 4, 2023
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category: Nursing and Physician Services Deficiencies
Corrected: Aug 4, 2023
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Category: Administration Deficiencies
Corrected: Aug 4, 2023
Observe each nurse aide's job performance and give regular training.
Category: Nursing and Physician Services Deficiencies
Corrected: Aug 4, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 3, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 15, 2023
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 1, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 1, 2023
Perform COVID19 testing on residents and staff.
Category: Infection Control Deficiencies
Corrected: Sep 23, 2022
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Sep 23, 2022
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.
Category: Pharmacy Service Deficiencies
Corrected: Sep 23, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 3.1% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 8.7% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.5% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.4% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 3.8% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.9% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 72.2% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 63.8% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 2.7% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 8.5% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 17.0% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 98.6% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 63.8% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 7.9% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 20.9% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 14.4% | Yes |
Penalty History 4 penalties totaling $272K
| Date | Type | Amount |
|---|---|---|
| Feb 20, 2025 | Fine | $45K |
| Nov 8, 2024 | Fine | $187K |
| Dec 5, 2023 | Fine | $16K |
| Dec 5, 2023 | Payment Denial | - |
| Jul 12, 2023 | Fine | $90K |
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Frequently Asked Questions
What is the overall CMS rating for CHI FRANCISCAN VILLA?
What are the staffing levels at CHI FRANCISCAN VILLA?
How many beds does CHI FRANCISCAN VILLA have?
Does CHI FRANCISCAN VILLA have any deficiencies on record?
Has CHI FRANCISCAN VILLA received any fines or penalties?
Who owns CHI FRANCISCAN VILLA?
When was CHI FRANCISCAN VILLA last inspected?
What quality measures are tracked for CHI FRANCISCAN VILLA?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.