Wheaton Franciscan Terrace at St Francis: Hand Hygiene Fail - WI
That is what inspectors found at Wheaton Franciscan Health Care, the Terrace at St. Francis, during a complaint inspection on October 28, 2025.
CNA-F and CNA-G were the staff involved. The resident was identified in inspection records only as R3. The mechanical lift, a piece of shared equipment moved from room to room and used to hoist residents who cannot reposition themselves, went unwiped after the transfer was complete.
When the surveyor raised the findings with Nursing Home Administrator A and Director of Nursing B that afternoon at 3:01 PM, the facility offered no explanation. The inspection report states plainly that no additional information was provided as to why the two nursing assistants skipped hand hygiene or failed to clean the lift.
The next morning, at 7:37 AM, a surveyor interviewed Registered Nurse H, who said that RN-I serves as the facility's infection preventionist, the staff member whose job is specifically to track and prevent the spread of infection inside the building. RN-H said staff had been trained on hand hygiene roughly two months before the inspection.
The training, as RN-H described it, covered exactly what CNA-F and CNA-G failed to do. Staff are expected to perform hand hygiene before entering a resident's room, before performing any care activity, and again before leaving the room. That is the standard the facility's own infection preventionist oversees. That is what did not happen.
Hand hygiene failures in nursing homes are not paperwork violations. Residents in long-term care are among the most vulnerable people to healthcare-associated infections, many of them elderly, with weakened immune systems, open wounds, urinary catheters, or feeding tubes that create direct pathways for bacteria to enter the body. Mechanical lifts, because they contact multiple residents across multiple rooms, are a recognized vector for spreading pathogens when they are not cleaned between uses.
CMS classified the harm level as minimal or potential for actual harm, and noted that only a few residents were affected. That classification reflects the agency's formal severity scale, not a judgment that the lapse was inconsequential.
What the inspection record does not contain is any account of the facility identifying the problem on its own. The concern was raised by the surveyor. The facility's response, when asked to explain what happened, was silence.
The Terrace at St. Francis is part of Wheaton Franciscan Healthcare, a Catholic health system operating in the Milwaukee area. The inspection was conducted as a complaint survey, meaning someone, a resident, a family member, or a staff member, had contacted regulators before inspectors arrived.
RN-H's account of the training timeline makes the lapse harder to dismiss as a gap in knowledge. Two months is recent enough that the content should have been fresh. The expectation, as RN-H described it, is not complicated: wash your hands going in, wash them before you touch the resident, wash them on the way out. The mechanical lift adds one more step, wiping down shared equipment, that did not happen either.
The facility had not, as of the inspection record, provided any explanation for why two staff members skipped all of it.
R3, the resident who was transferred that day, is identified in the record only by that designation. What condition required the use of a mechanical lift, how long she has lived at the facility, whether she has a family member who knows what inspectors found — none of that is in the report. What is in the report is that on October 28, 2025, two nursing assistants moved her from one position to another without the most basic infection control measure in place, and the facility, when asked why, had nothing to 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: 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.
That is what inspectors found at Wheaton Franciscan Health Care, the Terrace at St.
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.