Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Chi Franciscan Villa
SOUTH MILWAUKEE, WI · 90 certified beds · Last Life Safety survey May 29, 2026
CMS Certification Number 525526 · first certified November 1993
Ownership
Operated by COMMONSPIRIT HEALTH · Non profit - Other
- Ownership changed August 1, 2017 (change of ownership)to FRANCISCAN VILLA from FRANCISCAN VILLA OF SOUTH MILWAUKEE, INC.
Position within WI
35 citations — more than 94% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 13.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens July 2027 — about 9 months from now. This facility’s last Life Safety survey was May 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
7 of the 35 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
11 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 35 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 35 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 5, 2023 | 11 |
| February 20, 2025 | 16 |
| May 29, 2026 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2026-05-29 |
| K-0222 | 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. | 2 | 2026-05-29 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2026-05-29 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-02-20 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2026-05-29 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-02-20 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2026-05-29 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2025-02-20 |
What the citations cover
- Smoke Deficiencies 12
- Emergency Preparedness Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Egress Deficiencies 6
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Emergency Preparedness Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Egress Deficiencies | 6 |
| Miscellaneous Deficiencies | 3 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 29, 2026 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (June 19, 2026) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (June 19, 2026) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (June 25, 2026) |
| K-0222 | 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. | Deficient, Provider has date of correction (June 26, 2026) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (June 25, 2026) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (June 25, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 25, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 25, 2026) |
February 20, 2025 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (March 20, 2025) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (March 20, 2025) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (March 20, 2025) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (March 20, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (March 20, 2025) |
| K-0222 | 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. | Deficient, Provider has date of correction (February 27, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (February 27, 2025) |
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (February 27, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 27, 2025) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (March 20, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 20, 2025) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (March 20, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 20, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 20, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 20, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 20, 2025) |
December 5, 2023 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Waiver has been granted (December 2, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (December 26, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 29, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (December 22, 2023) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (December 26, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 20, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (January 14, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 27, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (December 1, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.