Wheaton Franciscan Terrace: Neglect Complaints Hidden - WI
That resident, identified in inspection records as R3, was one of several people at Wheaton Franciscan HC, Terrace at St. Francis who raised neglect concerns about the same certified nursing assistant in the summer and fall of 2025. The facility logged the complaints. It did not investigate them. It did not report them to the Wisconsin State Survey Agency. When a federal surveyor arrived in late October, administrators acknowledged both failures and could not explain either one.
R3 had been a resident at the facility since before August, living with atherosclerotic heart disease, atrial fibrillation, iron deficiency anemia, hypothyroidism, major depressive disorder, and dementia. In August 2025, she was discharged to the hospital and returned on September 11 with a new diagnosis: a non-displaced oblique fracture of the distal shaft of her left femur, a break in the lower portion of the thighbone. A mental status assessment completed five days after her return scored her at 12 out of 15, placing her in the moderately cognitively impaired range. She was not showing mood or behavior symptoms at the time.
When the surveyor interviewed R3 on October 27, she was alert and oriented to person, place, and time.
What R3 described, and what other residents described in written grievances, pointed to a pattern centered on one employee, identified in the inspection report only as CNA-F.
The grievance dated August 8 was R3's own account. She said she was extremely late to lunch that day because CNA-F and his phone got her up. She said her care was put on pause so CNA-F could take a call about care issues.
A second grievance, dated August 27, documented complaints from multiple residents. Showers had gone undone, with CNA-F logging repeated refusals while other staff were able to complete the same task with the same residents. One resident said she had spilled food from her bedside table and asked CNA-F to help clean it up. He refused. Another resident said she wanted to get up and be ready for therapy. CNA-F came to her room, turned off the light, and left. A third resident, described in terms matching R3's earlier complaint, said she was extremely late to breakfast because CNA-F was on his phone instead of helping her get cleaned up.
Four residents. Three specific incidents beyond the phone. A pattern documented in the facility's own grievance log.
None of it triggered a report to the state.
On October 28, the surveyor spoke with the facility's social worker, identified as SW-I. The social worker said her role in the grievance process was limited to entering complaints into a spreadsheet. She was not involved in investigating allegations of neglect or abuse. She was not involved in the grievance process beyond data entry.
That same morning, at 11:10, the surveyor spoke with the nursing home administrator, identified as NHA-A. The administrator confirmed that the facility had no formal grievance process in place. When the surveyor explained that multiple residents, including R3, had raised neglect concerns that were never reported to the State Survey Agency and never thoroughly investigated, the administrator said she would look for additional information about the allegations. She acknowledged understanding the concern.
Later that afternoon, the surveyor returned to the administrator and the director of nursing, identified as DON-B, and raised the same concern a second time. No additional information was provided. No explanation was offered for why the reports had not been made.
The regulation at issue, cited as F0609, requires nursing homes to report allegations of neglect to the state agency and to a long-term care ombudsman within two hours if the allegation involves serious bodily injury, or within 24 hours otherwise. It also requires a written report of investigation findings within five working days. The grievances involving CNA-F described residents being left unattended, denied basic hygiene assistance, and refused help with simple tasks. The first complaint was filed in August. The surveyor arrived in late October.
More than two months had passed.
The inspection classified the violation as causing minimal harm or potential for actual harm, affecting a few residents. That classification sits at the lower end of the federal harm scale, but it reflects what inspectors could document, not necessarily what residents experienced in the gap between when complaints were filed and when anyone outside the building learned of them.
The social worker's description of her role is worth sitting with. She entered grievances into a spreadsheet. That was it. She did not investigate. She was not expected to investigate. In a facility where the administrator confirmed there was no formal grievance process, the spreadsheet appears to have been the process. Complaints arrived, were recorded, and stopped moving.
CNA-F is not named in the inspection report, and the report does not document what, if any, action the facility took regarding his employment or conduct. The inspection record contains no indication that he was suspended, retrained, or removed from resident care during the period between the August complaints and the October survey. The report does not say he was not, either. It simply does not say.
What the report does say is that R3, a woman in her later years managing a broken leg and moderate cognitive impairment on top of a constellation of other diagnoses, told the facility in writing that a staff member chose his phone over her care. She said it in August. She was still living in the facility when the surveyor arrived in October and found her alert, oriented, and apparently unaware that her complaint had never left the building.
The surveyor found her that way on a Monday morning, two days before the inspection closed.
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 neglect violations during a health inspection on October 29, 2025.
That resident, identified in inspection records as R3, was one of several people at Wheaton Franciscan HC, 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.