Wheaton Franciscan Terrace: Neglect Reports Buried - WI
When a federal surveyor arrived at the facility on October 27, 2025, and began pulling grievance records, what she found was a paper trail of neglect allegations that had gone nowhere for months.
The resident at the center of the inspection, identified in records as R3, is a woman living with dementia, heart disease, an underactive thyroid, iron deficiency anemia, major depressive disorder, and paroxysmal atrial fibrillation, a condition in which the heart beats erratically before temporarily correcting itself. She had been a resident at the facility before being discharged to a hospital on August 18, 2025. She came back on September 11 with a new diagnosis: a non-displaced oblique fracture of the distal shaft of her left femur, a broken leg. A cognitive assessment completed five days after her return scored her at 12 on a standardized scale, placing her in the moderately cognitively impaired range. When the surveyor interviewed her directly on October 27, she was alert and oriented to person, place, and time.
Her grievance, filed on August 8, 2025, described what happened on a morning when the nursing assistant assigned to her, identified in records as CNA-F, stopped her care to take a phone call. R3 stated she was "extremely late to lunch" because CNA-F had paused her morning cares to handle the call. By the time the surveyor reviewed the grievance log on October 27, that complaint was more than two months old.
What the facility's own documentation showed was that R3's complaint was not an isolated incident. The counseling record for CNA-F, dated August 27, 2025, listed a pattern of behavior across multiple residents. Showers were not being completed, with CNA-F logging repeated refusals while other staff members were able to get the same residents bathed without difficulty. One resident had asked for help cleaning up food that had spilled from her bedside table and was refused. Another resident had asked to get up so she could be ready for therapy. CNA-F came to the room, turned off the light, and left.
The facility knew all of this in August. The counseling session for CNA-F happened on August 27. A second grievance from R3 was filed on September 8. The state survey agency, which is required to receive reports of neglect allegations, received nothing.
When the surveyor asked the facility's social worker, identified as SW-I, about the grievance process on October 28, SW-I said her role was limited to entering complaints onto a spreadsheet. She was not involved in investigating any allegations of neglect or abuse. That was the extent of the facility's system for handling a resident's report that a staff member had refused to help her, left her in the dark, or let her sit unready while a phone call took priority.
At 11:10 that same morning, the surveyor spoke with the nursing home administrator, identified as NHA-A. The administrator confirmed it directly: there was no formal grievance process currently in place at the facility. NHA-A acknowledged that multiple residents, including R3, had raised concerns about neglect that were never reported to the state and never thoroughly investigated. The administrator said they would look for additional information about the allegations.
That afternoon, the surveyor returned to raise the same concern again, this time with both the administrator and the Director of Nursing, identified as DON-B. The findings had not changed. The allegations of neglect had not been thoroughly investigated. The investigation findings had not been submitted to the state survey agency. No explanation was offered for why.
The timeline matters because it is not a matter of a complaint slipping through a gap. The facility's own grievance log documented R3's complaint on August 8. The counseling record for CNA-F, created August 27, showed that managers were aware of complaints from at least three residents. A second grievance from R3 appeared on September 8. The surveyor's inspection took place October 27 through October 29. That is a span of nearly three months during which the facility held documentation of neglect allegations against a single staff member involving multiple residents, issued what amounted to a written warning to that employee, and reported none of it to the agency responsible for oversight.
The regulations governing nursing homes that receive Medicare and Medicaid funding require facilities to report allegations of neglect to the state licensing agency. When the alleged violation involves neglect and does not result in serious bodily injury, the report is due within 24 hours. A written report of the investigation findings is required within five working days. The facility's own policy, reproduced in the inspection record, described those same requirements in detail.
What the facility's policy said and what the facility did were not the same thing.
R3 came back from the hospital in September with a broken leg, moderately impaired cognition, and a history of heart disease that her arteries' narrowing makes worse over time. She was dependent on the staff around her for her morning care, her meals, her showers, her ability to get out of bed and into therapy. When she told the facility that a nursing assistant had stopped her care to take a phone call and left her late for a meal, the facility wrote it down and did nothing more.
The surveyor found her alert and oriented on October 27. She knew where she was. She knew what had happened.
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 neglect violations during a health inspection on October 29, 2025.
She had been a resident at the facility before being discharged to a hospital on August 18, 2025.
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.