Wheaton Franciscan Terrace at St Francis: Fall Care Failures - WI
The resident, identified in inspection records only as R27, was a hospice patient at the 3200 S. 20th Street facility when she fell. The facility conducted what's called a root cause analysis after the fall, a standard internal review meant to identify what went wrong and what should change. That report indicated R27 should receive a therapy evaluation.
She didn't get one.
When an inspector arrived on August 19, a physical therapy assistant confirmed that R27 had last been seen by speech therapy in July, before the fall, and had received no order for physical or occupational therapy since the fall happened. The physical therapy assistant noted that therapy doesn't generally work with hospice patients but can evaluate them with hospice approval. No such approval had been sought. No evaluation had been scheduled.
The next morning, the inspector sat down with the facility's nursing home administrator and its director of nursing. Both acknowledged that yes, R27 should have been evaluated for therapy, per the root cause analysis. Neither could say whether it had happened. They told the inspector they would have to get back to her with more information.
They never did.
At 12:51 that afternoon, the inspector informed the facility of her concerns. The facility offered no comment and provided no further information before the inspection closed.
The care plan the facility produced for R27 during the inspection raised its own questions. The document listed toileting instructions, noting she should be assisted "upon rising, before meals, after meals and before bed time, whenever seeming anxious." But the care plan carried no dates, no revision history, no record of when it was created or last updated. There was no way to tell whether the fall on August 10 had prompted any change to her care at all, or whether anyone had touched the document since before she fell.
The deficiency was cited under F0689, which covers accidents and the environment of care, and was classified as minimal harm or potential for actual harm, with few residents affected.
That classification reflects the regulatory floor, not necessarily the full picture. R27 was on hospice, meaning she had already been determined to have a terminal illness with a prognosis of six months or less. People on hospice are not pursuing curative treatment. They are, by definition, in a period of heightened vulnerability, where the margin for error is narrow and the consequences of neglected care can move quickly.
A fall in that context is not a minor administrative matter. A fall for a hospice patient raises immediate questions about pain, about mobility, about whether the dying process is being made harder than it has to be. The root cause analysis the facility itself produced recognized this. It called for a therapy evaluation. That evaluation is how you find out whether something broke, whether something shifted, whether the fall changed what this person needs to get through her days.
Ten days passed. The evaluation didn't happen. The care plan sat undated. The administrator and the director of nursing told the inspector they'd look into it.
The inspection was completed August 20, 2025. By then, the only thing confirmed was what hadn't been done.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wheaton Franciscan Hc - Terrace At St Francis from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
Wheaton Franciscan HC - Terrace at St Francis in MILWAUKEE, WI was cited for violations during a health inspection on August 20, 2025.
The resident, identified in inspection records only as R27, was a hospice patient at the 3200 S.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.