Wheaton Franciscan Terrace at St Francis: ADL Failures - WI
The surveyor was watching.
The resident, identified in inspection records only as R1, is entirely dependent on staff for his daily care. He cannot do these things himself. When the surveyor returned to his room later that morning, on October 28, 2025, R1 was lying in bed, unshaved, hair still uncombed. The surveyor asked him directly whether anyone had used a toothbrush or mouthwash before breakfast that morning.
He said no.
That afternoon, the surveyor asked CNA-J, the aide who had performed morning care, when she does oral care for R1. Probably every other day, she said. She explained that R1 can't open his mouth very wide and she didn't think a toothbrush would fit. The surveyor asked whether the facility had toothette oral swabs for situations like that. CNA-J said she didn't know if they had those.
The conversation continued. The surveyor asked about shaving. CNA-J said R1's wife shaves him when she comes in. The surveyor asked about brushing or combing his hair. CNA-J said R1's wife brings in shampoo, she thinks it's Selsun Blue, and his wife brushes his hair after washing it. The surveyor asked whether CNA-J herself ever brushes or combs his hair.
She replied no.
Less than an hour later, the surveyor raised these findings with the Registered Nurse and Interim Unit Manager, identified in the report as RN/IUM-M. The surveyor asked, in sequence, whether staff shave residents. Yes, said the manager. Whether they brush or comb residents' hair. Yes. Whether staff does oral care. Yes. The surveyor then told the manager what the morning observation had shown: that CNA-J had completed R1's bath without offering or performing oral care, shaving, or grooming.
No additional information was provided.
What the inspection captured was a gap between what the unit manager described as standard practice and what CNA-J had been doing, apparently for some time. The aide had not framed her approach as a one-time oversight. She spoke in patterns: every other day, when his wife comes in, his wife does it. The wife's visits had become a substitute for staff care, and the aide did not appear to recognize that as a problem.
The pressure injury treatment to R1's toes was completed that morning, documented and performed according to physician orders. The suprapubic catheter site was cleaned. The soiled linen was removed and replaced. The clinical tasks were done. What was skipped were the parts of care that don't generate a wound note or a catheter entry in the chart, the parts a bedridden man cannot perform or request for himself and cannot easily report when they don't happen.
Oral care for a person who cannot independently brush their teeth is not a comfort measure. Bacteria accumulate in the mouth. For someone immobile, the risks compound. CNA-J's explanation that she didn't know whether the facility had swabs for residents who can't open their mouths wide was not a clinical judgment. It was a gap in training, or attention, or both.
The inspection was completed October 29, 2025, at Wheaton Franciscan HC, Terrace at St Francis, located at 3200 S. 20th Street in Milwaukee. CMS assigned the violation a harm level of minimal harm or potential for actual harm. The deficiency affected a few residents.
R1's wife was not interviewed in the inspection record. She had been coming in to wash his hair and shave his face. Whether she knew that staff had stopped doing these things, or whether she had simply filled in without anyone acknowledging the arrangement, the report does not say.
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 2025-10-29 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: June 23, 2026 · Our methodology
Wheaton Franciscan HC - Terrace at St Francis in MILWAUKEE, WI was cited for violations during a health inspection on October 29, 2025.
The resident, identified in inspection records only as R1, is entirely dependent on staff for his daily care.
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.