Wheaton Franciscan Terrace at St. Francis: Catheter Failures - WI
"Oh my God I didn't even notice it," LPN-E told the surveyor. "I'll put one on."
The resident, identified in inspection records as R1, has multiple sclerosis, spastic paraplegia, and a neurological condition that impairs bladder control. His cognitive status, assessed three weeks before the inspection, placed him in the range of severe impairment, with a BIMS score of 7. He cannot toilet himself. He depends entirely on staff to manage his suprapubic catheter, a tube inserted directly through the abdomen into the bladder.
His physician ordered a STATLOCK device to secure the catheter tubing, with instructions to change it weekly or whenever it became loose or caused skin problems. The order was dated October 8, 2025. His care plan had included the same instruction since September 11. When a surveyor observed morning care on October 28, no STATLOCK was present.
The device's absence wasn't the only problem inspectors found that morning.
At 8:40 a.m., CNA-J emptied R1's urine collection bag, draining 400 cubic centimeters of yellow urine into a graduate container, then carried it to the bathroom, poured it into the toilet, and rinsed the graduate. What she did not do was clean the end of the drainage spigot with an alcohol pad before placing it back in its holder. The facility's own catheter care policy requires staff to avoid contaminating the spigot during emptying. Cleaning the tip is a basic step against infection.
R1 has a condition in which the nerves and muscles controlling his bladder don't function normally. Patients with indwelling catheters already face elevated infection risk. Skipping that alcohol wipe is not a minor procedural gap.
The Director of Nursing, DON-B, when asked by the surveyor about the correct procedure for emptying a catheter bag, described the steps accurately and in order: gloves on, remove spigot, empty, clean the tip, place back in holder, empty in commode, rinse. She did not know, until the surveyor told her, that her staff had skipped the cleaning step on R1 that morning.
The surveyor had been watching R1 since the day before. On October 27, at 10:06 a.m., R1 was in bed on his back with the head elevated, his urine collection bag hanging from the bed frame on his left side. The surveyor returned the next morning and observed the full sequence of morning care, from 8:30 a.m. to 9:16 a.m., including the catheter bag emptying, the absence of the alcohol wipe, and the absent STATLOCK. The LPN was not asked about the securing device until 10:33 that morning, nearly two hours after care had ended.
The inspection was a complaint survey, completed October 29, 2025. CMS rated the harm level as minimal harm or potential for actual harm.
R1 cannot raise the issue himself. His BIMS score of 7 means he cannot reliably communicate, orient to time or place, or advocate for the care his doctor ordered. He is dependent for toileting. He does not know whether the device holding his catheter in place has been changed on schedule, or whether the person emptying his urine bag cleaned the spigot before putting it back.
He is relying on a system that, on at least one observed morning, didn't notice it had skipped both steps.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 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.
"Oh my God I didn't even notice it," LPN-E told the surveyor.
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.