Chi Franciscan Villa: Accident Hazard Harm - WI
The resident, identified as R2 in inspection records, told surveyors the family had brought in a door mat and placed the folded sheet on top to prevent falls. Staff throughout the facility knew it was a trip hazard. They left it there anyway.
"R2 specifically requested it to be there because R2's legs are currently leaking and R2 does not want the floor to get wet," certified nursing assistant CNA-D told inspectors when asked about the setup.
When pressed about what happens when residents make unsafe requests, the nursing assistant couldn't answer. "CNA-D was not sure, but the nurse on duty would know the process."
Unit Manager-F did know the process. Staff should educate residents on safe practices, complete a risk-versus-benefits analysis, and update the care plan to include the request if approved. But no such documentation existed for R2's floor covering.
"Unit Manager-F was not aware the folded-up sheet was in R2's room," inspectors noted.
The unit manager immediately recognized the problem when told about it. Yes, that's a trip hazard. The manager promised to educate R2 and remove the sheet.
But the safety failures ran deeper than a single folded sheet. R2's room had no signage reminding the resident to wait for assistance, despite a care plan requiring such reminders. R2 confirmed to inspectors that no signs had ever been posted.
The resident's fall risk evaluation, completed just over a month earlier, contained a critical error that artificially lowered the assessed danger level.
MDS coordinator-G admitted to accidentally skipping a medication question on R2's October 9 assessment. The coordinator "must have accidentally clicked to the next page, and the fall risk evaluation was not completed correctly."
That missing answer mattered. The resident should have been marked as taking three to four fall-risk medications, which would have resulted in a higher overall fall risk score and potentially triggered additional safety interventions.
The coordinator only completes these evaluations quarterly when prompted by the electronic health record system. Other nursing staff handle assessments after falls or condition changes, creating a fragmented process where critical details slip through gaps.
Director of Nursing DON-B acknowledged that staff had previously discussed trip hazards with R2's family. The conversations apparently didn't resolve anything. The family kept bringing items that created fall risks, and staff kept allowing them to remain.
When inspectors raised concerns about both the trip hazard and missing signage, nursing leadership offered no explanation for why proper fall interventions weren't in place for a resident who had already fallen once.
The facility's own online training covers trip hazards, according to CNA-D. Every staff member interviewed recognized that a folded sheet on the floor presented a danger to residents moving around their rooms.
Yet the system designed to prevent falls had multiple breakdowns. Accurate risk assessments weren't completed. Required signage wasn't posted. Unsafe conditions were tolerated because residents or families requested them, even without proper documentation or approval processes.
R2's original fall occurred during a bathroom transfer, one of the most dangerous activities for nursing home residents. The subsequent safety measures - a makeshift floor covering that staff knew created new hazards - illustrated how the facility's fall prevention program had failed to address the underlying transfer difficulties that caused the initial injury.
Administrator NHA-A and the director of nursing provided no additional information about why proper fall interventions remained absent weeks after R2's bathroom fall, or why staff had allowed an inaccurate risk evaluation to stand uncorrected for over a month.
The folded sheet remained in place until inspectors discovered it during their November visit.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chi Franciscan Villa from 2025-11-13 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 20, 2026 · Our methodology
Chi Franciscan Villa in SOUTH MILWAUKEE, WI was cited for violations during a health inspection on November 13, 2025.
The resident, identified as R2 in inspection records, told surveyors the family had brought in a door mat and placed the folded sheet on top to prevent falls.
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.