Deficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Enforcement
Deficiencies: 2
Sep 19, 2025
Visit Reason
A verification visit and three complaint investigations were conducted to determine if Francis House was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #8TU713) citing violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation, Orders to Comply, Special Orders to address environmental and safety concerns, and a total forfeiture of $500.00.
Complaint Details
Three complaint investigations were concluded as part of the verification visit to determine compliance with applicable statutes and codes.
Deficiencies (2)
| Description |
|---|
| Violations identified in Statement of Deficiency (SOD) #8TU713 related to environmental concerns including flooring, furniture, and fixtures that cannot be properly cleaned or repaired. |
| Failure to conduct emergency evacuation drills in accordance with Wis. Admin. Code § DHS 83.47(2)(e). |
Report Facts
Forfeiture amount: 500
Forfeiture amount: 300
Forfeiture amount: 200
Days to comply: 45
Days to request extension: 10
Days to notify legal representatives: 7
Reduced forfeiture amount: 325
Revisit inspection fee: 200
Days to pay forfeiture: 10
Days to pay revisit fee: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter. |
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter. |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 64
Deficiencies: 5
Sep 17, 2025
Visit Reason
Surveyors conducted three complaint investigations and a verification visit for a prior Statement of Deficiencies at Francis House, a Community-Based Residential Facility, to assess compliance with regulatory requirements.
Findings
Five deficiencies were identified, including repeat violations related to grievance procedure posting, medication storage, facility environment cleanliness and maintenance, toxic substance storage, and failure to complete required evacuation drills. Three complaints were unsubstantiated.
Complaint Details
Three complaints were investigated and all were unsubstantiated.
Deficiencies (5)
| Description |
|---|
| The provider did not ensure the grievance procedure was posted in the facility. |
| Medications for Resident 16 were not securely stored; unsecured medications were left on the resident's tray. |
| The facility was not maintained in a safe, clean, comfortable, and homelike environment, with issues such as strong urine odor, dirty kitchen, damaged flooring, peeling wallpaper, and unclean resident rooms. |
| Cleaning compounds and toxic substances were stored in an unlocked cabinet under the kitchen sink, accessible to residents. |
| The provider did not ensure that required other evacuation drills (e.g., tornado, flooding) were completed in 2025. |
Report Facts
Deficiencies identified: 5
Repeat violations: 2
Revisit fee: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding grievance procedure posting, medication administration, facility environment concerns, and toxic substance storage. |
| ED A | Executive Director | Interviewed regarding other evacuation drills and responsible for providing documentation. |
| Caregiver D | Interviewed about cleaning compounds stored under kitchen sink. | |
| Caregiver C | Interviewed about cleaning compounds stored under kitchen sink. |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Aug 18, 2025
Visit Reason
Surveyor conducted a complaint investigation at Francis House, a Community-Based Residential Facility, triggered by a complaint regarding the facility's menu practices.
Findings
The facility did not ensure a weekly menu was prepared and made available to residents. The posted menu was outdated and incomplete, lacking breakfast information, and staff confirmed no menu was followed for breakfast.
Complaint Details
Complaint substantiated.
Deficiencies (1)
| Description |
|---|
| The provider did not ensure a weekly menu was prepared and available to 43 of 43 residents. |
Report Facts
Census: 43
Items on breakfast cart: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Assistant B | Resident Assistant | Interviewed regarding breakfast menu practices. |
| Executive Director A | Executive Director | Interviewed and confirmed no weekly menu was made available to residents. |
Inspection Report
Routine
Census: 38
Capacity: 64
Deficiencies: 5
Apr 11, 2025
Visit Reason
Surveyor conducted a standard survey, two complaint investigations, and a verification visit at Francis House, a Community-Based Residential Facility (CBRF) in South Milwaukee, WI.
Findings
Five deficiencies were identified, four of which were repeat violations from a prior survey dated 04/17/2023. Two complaints were unsubstantiated. Deficiencies included failure to have residents' or their legal representatives' signatures on Individual Service Plans, incomplete documentation of medication administration, unsafe and unclean environment conditions, failure to conduct required evacuation drills, and water temperatures exceeding regulatory limits.
Complaint Details
Two complaints were investigated and found to be unsubstantiated.
Deficiencies (5)
| Description |
|---|
| Resident Individual Service Plans (ISP) were not signed by residents or their legal representatives acknowledging involvement and agreement. |
| Documentation of medication administration was incomplete for three residents, missing time, dosage, and initials on medication administration records. |
| Facility environment was not maintained in a safe, clean, comfortable, and homelike condition, including dirty kitchen areas, damaged walls, and malfunctioning sink cabinet doors. |
| Other evacuation drills (e.g., tornado, flooding) were not conducted at least semi-annually for calendar year 2024. |
| Water temperatures at resident bathroom fixtures exceeded the maximum allowed 115°F, with readings up to 140°F. |
Report Facts
Revisit fee: 200
Number of deficiencies identified: 5
Number of repeat violations: 4
Census: 38
Total licensed capacity: 64
Missing medication administration entries: 22
Missing medication administration entries: 22
Missing medication administration entries: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| B | Director of Nursing | Interviewed regarding ISPs not signed by POAs and medication administration documentation deficiencies. |
| A | Executive Director | Interviewed regarding lack of evacuation drills and water temperature issues. |
| K | Plant Operations Director | Responsible for maintenance and conducting evacuation drills; referenced in interviews. |
Inspection Report
Enforcement
Deficiencies: 0
Apr 11, 2025
Visit Reason
A standard survey, two complaint investigations, and a verification visit were conducted to determine if Francis House was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency #8TU712 and imposed a total forfeiture of $1,300.00. A $200 inspection fee was also assessed for a revisit to verify correction of prior violations.
Complaint Details
Two complaint investigations were part of the visit, but the substantiation status is not explicitly stated in the document.
Report Facts
Forfeiture amount: 1300
Reduced forfeiture amount: 845
Forfeiture breakdown: 400
Forfeiture breakdown: 450
Forfeiture breakdown: 150
Forfeiture breakdown: 300
Inspection fee: 200
Compliance timeframe: 45
Appeal timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 17, 2023
Visit Reason
A standard licensure survey and two complaint investigations were conducted to determine if Francis House was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #8TU711) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a notice of violation and an imposed forfeiture totaling $1,500.00.
Complaint Details
Two complaint investigations were concluded along with the standard licensure survey. The Department found violations substantiated as detailed in SOD #8TU711.
Report Facts
Forfeiture amount: 1500
Forfeiture amount: 300
Forfeiture amount: 800
Forfeiture amount: 400
Reduced forfeiture amount: 975
Compliance timeframe: 45
Payment timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter |
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
Inspection Report
Routine
Census: 40
Capacity: 64
Deficiencies: 8
Apr 17, 2023
Visit Reason
The surveyor conducted a standard licensure survey and two complaint investigations at Francis House.
Findings
Eight deficiencies were identified including one substantiated complaint and one unsubstantiated complaint. Deficiencies involved environmental hazards, service plan development, PRN psychotropic medication documentation, medication administration documentation, hand washing practices, facility cleanliness and maintenance, and fire and evacuation drills.
Complaint Details
Two complaint investigations were conducted; one complaint was substantiated related to residents exiting the facility without staff acknowledgement due to door alarm failure, and one complaint was unsubstantiated.
Deficiencies (8)
| Description |
|---|
| Residents were not safeguarded from environmental hazards; Resident 6 eloped due to a door alarm failure. |
| Resident Individual Service Plans (ISPs) were not signed by residents or their legal representatives for 4 of 4 records reviewed. |
| Resident 3's PRN psychotropic medication Lorazepam was not documented in the ISP with rationale or behavior description. |
| Medication Administration Records (MAR) for Residents 3 and 5 contained undocumented medication administrations and discrepancies. |
| Employees did not follow proper hand washing procedures according to CDC standards during observed care activities. |
| Facility environment was not safe, clean, comfortable, and homelike; multiple areas showed dirt, food residue, damage, and maintenance issues. |
| Quarterly fire drills, including at least one during usual sleeping hours, were not conducted in 2021 and 2022. |
| Semi-annual other evacuation drills (tornado, flooding, or other emergencies) were not conducted in 2021 and 2022. |
Report Facts
Deficiencies identified: 8
Residents present (census): 40
Licensed capacity: 64
PRN Morphine administrations: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing B | Director of Nursing | Interviewed regarding door alarm failure, medication administration, hand hygiene, and care plan documentation. |
| Executive Director A | Executive Director | Interviewed regarding care plan signatures, hand hygiene, facility environment, and fire drill documentation. |
| Licensed Practical Nurse D | Licensed Practical Nurse | Observed not following proper hand washing procedures during blood draw. |
| Resident Assistant C | Resident Assistant | Observed not following proper hand washing procedures when assisting resident with eating. |
| Resident Assistant E | Resident Assistant | Observed not following proper hand washing procedures when donning and doffing gloves. |
Report
File
7KQ411ENFS.PDF_16783.pdf
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