Wheaton Franciscan Terrace at St. Francis: Hygiene Failures - WI
The inspection, completed October 29, 2025, documented what a surveyor watched firsthand. Two CNAs and a licensed practical nurse rotated in and out of the resident's room that morning, each handling a piece of his care. The LPN cleaned and treated a pressure injury on his toes. The aides washed his body, changed his incontinence product, repositioned him, put a fresh T-shirt on him, and placed pressure-relieving boots back on his feet. One told him she'd see him for lunch. Then they left.
The surveyor noted that no oral care had been performed or offered at any point.
The next morning, October 28, the surveyor returned and found the resident still in bed, unshaved, hair unbrushed. The surveyor asked him directly whether anyone had used a toothbrush or mouthwash before breakfast. He said no.
That afternoon, the surveyor asked CNA-J, the aide who had led his morning care, when she does oral care for the resident. Probably every other day, she said. She explained that he can't open his mouth wide, and she didn't think a toothbrush would fit. The surveyor asked whether the facility had toothette oral swabs for situations like that. CNA-J said she didn't know if they had them.
The surveyor asked about shaving. CNA-J said the resident's wife shaves him when she comes in.
The surveyor asked about brushing or combing his hair. CNA-J said the resident's wife brings in shampoo, she thinks it's Selsun Blue, and his wife brushes his hair after washing it. The surveyor asked whether CNA-J herself ever brushes or combs his hair.
She replied no.
The unit's interim nurse manager, identified in the report as RN/IUM-M, told the surveyor that yes, staff shave residents. Yes, they brush and comb hair. Yes, they do oral care. The surveyor then informed her what the morning observation had actually shown: that CNA-J had completed the resident's full morning routine without offering or performing any of those things.
No additional information was provided.
What makes the finding land harder than a single missed morning is the explanation CNA-J gave. She didn't describe a resident who had refused care. She didn't describe a hectic shift or a supply shortage she'd reported. She described a system where a dependent man's basic grooming had been quietly delegated to his wife, who comes in when she can, and where the aide responsible for his daily care didn't know whether the facility even stocked the adaptive supplies that might have helped.
The resident in this case is dependent on staff for his activities of daily living. That's not a clinical footnote. It means he cannot do these things for himself. When the people assigned to his care leave without doing them, they don't get done.
Oral hygiene matters in ways that compound quickly for people who can't manage it themselves. Bacteria in the mouth doesn't stay there. For residents who are already managing pressure injuries, catheters, and positioning needs around the clock, skipped oral care is not a minor inconvenience. It is a gap in a care system that is supposed to catch exactly these things.
The inspection was a complaint survey. Someone prompted it. The report does not say who.
What it does say is that when the surveyor watched morning care happen in real time, and then asked the resident himself whether anyone had attended to his mouth before breakfast, he said no. He was still lying in bed the next day, unshaved, hair untouched, waiting for his wife to come in.
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.
Download the official CMS inspection PDF from Medicare.gov
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 23, 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.
The inspection, completed October 29, 2025, documented what a surveyor watched firsthand.
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.