About Chi Franciscan Villa
Chi Franciscan Villa, located in SOUTH MILWAUKEE, WI, is a non-profit organization that accepts Medicare and Medicaid. This facility is part of a continuing care retirement community.
Why Families Choose Chi Franciscan Villa
Key Performance Indicators
- CMS Overall Rating 1 Stars
- Nursing Hours 3.16 hrs
- Safety Record Issues
Chain Affiliations & Network
This facility is part of the COMMONSPIRIT HEALTH network. This chain operates 19 facilities.
Chain Performance Overview
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Nursing Staff Analysis
Staffing levels are a critical indicator of quality care. We analyze the daily hours of care provided by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs).
Below Average Staffing
Chi Franciscan Villa provides less care hours than the state average and less than the national average.
Registered Nurses (RN)
Licensed Practical Nurses
Certified Assistants
CMS Quality Ratings
| Category | Rating | Stars |
|---|---|---|
| Overall Rating | 1 |
|
| Health Inspection | 1 |
|
| Quality Measures | 3 |
|
| Staffing | 1 |
|
Health Inspection History
| Inspection Cycle | Score | Date |
|---|---|---|
| Cycle 1 (Most Recent) | 240 | Feb 20, 2025 |
| Weighted Average | 289 | Combined Score |
Detailed Quality Measures
Rates are from CMS quality measures (claims-based and MDS-based) for the reporting period ending May 01, 2026. Some measures may be omitted when CMS does not report a numeric rate for this facility.
Medicare claims-based measures
Typically includes short-stay outcomes, hospitalizations, and ED use from Medicare claims.
| Measure | Rate |
|---|---|
| Percentage of short-stay residents who were rehospitalized after a nursi... (QM521) | 23.0% |
| Percentage of short-stay residents who had an outpatient emergency depar... (QM522) | 20.4% |
| Number of hospitalizations per 1000 long-stay resident days (QM551) | 2.4% |
| Number of outpatient emergency department visits per 1000 long-stay resi... (QM552) | 3.0% |
MDS-based measures
Resident assessment data; often used for long-stay care quality.
| Measure | Rate |
|---|---|
| Percentage of long-stay residents whose need for help with daily activit... (QM401) | 3.0% |
| Percentage of long-stay residents who lose too much weight (QM404) | 11.4% |
| Percentage of long-stay residents with a catheter inserted and left in t... (QM406) | 0.5% |
| Percentage of long-stay residents with a urinary tract infection (QM407) | 0.4% |
| Percentage of long-stay residents who have depressive symptoms (QM408) | 9.2% |
| Percentage of long-stay residents who were physically restrained (QM409) | 0.0% |
| Percentage of long-stay residents experiencing one or more falls with ma... (QM410) | 2.9% |
| Percentage of long-stay residents assessed and appropriately given the p... (QM415) | 64.7% |
| Percentage of short-stay residents assessed and appropriately given the... (QM430) | 61.4% |
| Percentage of short-stay residents who newly received an antipsychotic m... (QM434) | 4.0% |
| Percentage of long-stay residents whose ability to walk independently wo... (QM451) | 9.6% |
| Percentage of long-stay residents who received an antianxiety or hypnoti... (QM452) | 19.0% |
| Percentage of long-stay residents assessed and appropriately given the s... (QM454) | 98.6% |
| Percentage of short-stay residents who were assessed and appropriately g... (QM472) | 63.8% |
| Percentage of long-stay residents with pressure ulcers (QM479) | 9.4% |
| Percentage of long-stay residents with new or worsened bowel or bladder... (QM480) | 17.3% |
| Percentage of long-stay residents who received an antipsychotic medicati... (QM481) | 12.6% |
Complaints & Deficiencies
Complaint History by Year
This chart shows the number of complaints filed each year.
Summary:
- 2023: 9 complaints
- 2024: 12 complaints
- 2025: 15 complaints
- 2026: 10 complaints
- Total: 46 complaints on record
Recent Complaints (Since Jan 2023)
| Date | Description |
|---|---|
| Mar 16, 2026 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. |
| Mar 16, 2026 | 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. |
| Mar 16, 2026 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. |
| Mar 16, 2026 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. |
| Mar 16, 2026 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. |
| Mar 16, 2026 | Provide appropriate treatment and care according to orders, resident?s preferences and goals. |
| Mar 16, 2026 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. |
| Mar 16, 2026 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. |
| Mar 16, 2026 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. |
| Jan 26, 2026 | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. |
| Dec 05, 2025 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. |
| Dec 05, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. |
| Dec 05, 2025 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. |
| Dec 05, 2025 | Provide and implement an infection prevention and control program. |
| Aug 06, 2025 | Protect each resident from the wrongful use of the resident's belongings or money. |
| Jul 17, 2025 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. |
| Jul 17, 2025 | Respond appropriately to all alleged violations. |
| Jun 30, 2025 | Ensure each resident receives an accurate assessment. |
| Jun 30, 2025 | Provide care and assistance to perform activities of daily living for any resident who is unable. |
| Jun 30, 2025 | Provide enough food/fluids to maintain a resident's health. |
| 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. |
| Jun 30, 2025 | Provide and implement an infection prevention and control program. |
| Jun 12, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. |
| Feb 28, 2025 | Provide care and assistance to perform activities of daily living for any resident who is unable. |
| Feb 28, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. |
| Nov 20, 2024 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. |
| Nov 20, 2024 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. |
| Jul 05, 2024 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. |
| Jul 05, 2024 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. |
| Jan 02, 2024 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. |
| Jan 02, 2024 | Ensure medication error rates are not 5 percent or greater. |
| Jan 02, 2024 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. |
| Jan 02, 2024 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. |
| Jan 02, 2024 | Provide appropriate treatment and care according to orders, resident?s preferences and goals. |
| Jan 02, 2024 | Allow residents to self-administer drugs if determined clinically appropriate. |
| Jan 02, 2024 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. |
| Jan 02, 2024 | Respond appropriately to all alleged violations. |
| Sep 15, 2023 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. |
| Aug 04, 2023 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. |
| Aug 04, 2023 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. |
| Aug 04, 2023 | Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. |
| Aug 04, 2023 | Observe each nurse aide's job performance and give regular training. |
| Aug 03, 2023 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. |
| Jul 15, 2023 | Provide appropriate treatment and care according to orders, resident?s preferences and goals. |
| Jun 01, 2023 | Respond appropriately to all alleged violations. |
| Jun 01, 2023 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. |
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Owner & Operator Information
Business Entity
CHI LIVING COMMUNITIES
Ownership Structure
- COMMONSPIRIT HEALTH Indirect
- SYLVANIA FRANCISCAN HEALTH Direct: 100%
Management & Direction
- MICHAEL GULOCK W-2 MANAGING EMPLOYEE
- ALISA IFFLAND CORPORATE OFFICER
- PRENTICE LIPSEY CORPORATE OFFICER
- MITCH MELFI CORPORATE DIRECTOR
- HEATHER REHMER CORPORATE OFFICER
- TERIKA RICHARDSON MBANU CORPORATE DIRECTOR
Associated Doctors
Local Comparison
| Facility | Distance | Rating |
|---|---|---|
| Clement Manor Health Care Center | N/A | 5 |
| Milwaukee Catholic Home | N/A | 5 |
| Complete Care at Ridgewood LLC | N/A | 4 |
| Milwaukee Health and Rehab | N/A | 4 |
| Complete Care at Germantown | N/A | 4 |
| Brookside Care Center | N/A | 5 |
| St Ann Health and Rehabilitation Center | N/A | 4 |
| Complete Care at Hales Corners | N/A | 3 |
| Mercy Health Services | N/A | 3 |
| Congregational Home, Inc. | N/A | 4 |
Related Analysis
Best Nursing Homes in SOUTH MILWAUKEE, WI
Compare Chi Franciscan Villa to the top-rated facilities in the area.
Ownership Details
Complete list of registered owners, including direct and indirect ownership.
Noted Deficiencies
Detailed history of deficiencies with descriptions and correction dates.
Nursing Hours Analysis
Detailed breakdown of staffing hours per resident by role.
Frequently Asked Questions
- Skilled Nursing Care: 24/7 medical supervision and complex medical treatments
- Long-term Residential Care: Assistance with daily living activities for extended stays
- Short-term Rehabilitation: Recovery services after hospital stays or surgeries
- Memory Care: Specialized programs for residents with dementia and Alzheimer's disease
- Level of care needed (skilled nursing vs. long-term care)
- Room type (private vs. semi-private)
- Insurance coverage (Medicare, Medicaid, private insurance)
- Length of stay and specific services required
For current rates and to discuss payment options, contact Chi Franciscan Villa directly at 4147644100. Their admissions team can help determine coverage and out-of-pocket expenses.
Environment & Cleanliness
- Overall cleanliness and odors
- Resident room conditions
- Common area maintenance
- Safety features and accessibility
Staff & Care Quality
- Staff-to-resident ratios
- How staff interact with residents
- Response time to resident needs
- Staff knowledge and professionalism
Ask to speak with current residents and their families, tour at different times of day, and review the facility's most recent inspection reports.