Wheaton Franciscan Hc - Terrace At St Francis

F-F756.

Physician-BB's progress note dated 6/22/24 does not address Resident R5's PRN Ativan.

On 7/17/24, at 9:37 a.m., Surveyor met with RN/UM (Registered Nurse/Unit Manager)-AA to discuss Resident R5. Surveyor informed RN/UM-AA Surveyor wasn't able to locate a stop date or rationale to continue Resident R5's PRN Ativan. RN/UM-AA informed Surveyor Resident R5 is hospice and those order come from hospice. RN/UM-AA informed Surveyor she may have to touch base with DON (Director of Nursing)-B. Surveyor asked RN/UM-AA if she could get back to Surveyor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 On 7/17/24, at 12:24 p.m., RN/UM-AA informed Surveyor regarding Resident R5's PRN Ativan the hospice team are

the ones responsible for ordering the medication. Surveyor asked RN/UM-AA if there is a stop date or Level of Harm - Minimal harm or rational for continuing Resident R5's PRN Ativan. RN/UM-AA replied no not to our knowledge, its a matter of the potential for actual harm hospice team providing information which we haven't gotten. We are going to follow up on that.

Residents Affected - Few On 7/17/24, at 3:51 p.m., during the end of the day meeting with NHA (Nursing Home Administrator)-A Surveyor informed NHA-A there is no stop date or documented rationale beyond 14 days for Resident R5's PRN Ativan 0.5 mg.

On 7/18/24, at 10:20 a.m., Surveyor informed DON-B of the concern of Resident R5's PRN Ativan 0.5 mg does not have a stop date and Surveyor is unable to locate evidence of documented rationale as to why this medication needs to be extended by 14 days.

On 7/22/24, at 7:45 a.m., NHA-A provided Surveyor with physician orders for 7/18/24 which documents an order date of 5/6/24 Ativan Tab 0.5 mg - .5 mg by mouth every 8 hours as needed Administer .5 mg every eight hours by mouth for anxiety. [Physician-BB's name]; with a stop date of 11/02/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38829 potential for actual harm Based on interview, observation, and record review, the facility did not assist 1 (Resident R29) of 1 resident reviewed Residents Affected - Few for obtaining routine dental care.

Resident R29 has very few teeth, most are black in color and was not offered and did not receive dental services, resulting in being on a mechanically soft altered diet with tube feeding.

Findings Include:

The facility's policy Dental Services for Residents dated 6/2016 and last revised on 9/2018 documents:

.Policy Statement

Routine and emergency dental services are available to meet the Resident's oral health services in accordance with the Resident's evaluation and plan of care.

Policy Interpretation and Implementation

1. Oral health services are available to meet the Resident's needs.

3. Our community has a contract with a dentist that comes to the community and provides dental services.

4. Dental services are under the supervision of a licensed dentist retained by this community.

8. A complete record of the Resident's dental care and services are maintained in accordance with current regulations.

15. Dental services provided are recorded in the Resident's medical record.

17. Nursing services is responsible for notifying social services of a Resident's need for dental services.

18. Social services personnel will be responsible for assisting the Resident/and/or Resident representative in making dental appointments and transportation arrangements as necessary.

Resident R25 was admitted to the facility on [DATE REDACTED] with diagnoses of Rhabdomyolysis, Type 1 Diabetes Mellitus, Alcoholic Cirrhosis of Liver with Ascites. Legal Blindness, Acquired Absence of Right Leg Below Knee, Kidney Transplant, Pancreas Transplant, and Depression.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Resident R25's Admission MDS completed on 2/23/24 documents Resident R25 has a Brief Interview for Mental Status(BIMS) score of 11, indicating Resident R25 demonstrates moderately impaired skills for daily decision making. Resident R25's MDS Level of Harm - Minimal harm or also documents that Resident R25 has an indwelling catheter, is on a mechanically altered diet with a feeding tube, potential for actual harm has range of motion impairment on 1 side of lower extremity, requires partial/moderate assistance for mobility and substantial/maximum assistance for transfers. Residents Affected - Few Resident R25's Care Area Assessment (CAA) for nutrition dated 2/28/24 states see nutrition assessment.

Surveyor notes there is no care plan in place for Resident R25's dental concerns.

On 2/20/24, Dietitian (DIET)-Q documented in the Nutrition Risk Assessment that Resident R25 has chewing difficulty and is on mechanically soft diet with honey thick liquids. DIET-Q also documents that Resident R25 is receiving tube feedings. Nursing reported to DIET-Q that Resident R25 was only consuming pudding. DIET-Q documents that speech will be working with Resident R25 on diet texture.

On 7/15/24, at 10:00 AM, Resident R25 was interviewed by Surveyor and Resident R25 stated Resident R25 has not been offered dental services and would like to see a dentist to get Resident R25's teeth removed so Resident R25 can get dentures to eat better. Surveyor observed only 4-5 teeth in Resident R25's mouth and the teeth are black in color. Resident R25 stated most of Resident R25's upper teeth are gone and Resident R25 has difficulty in chewing. Resident R25 stated no one has asked Resident R25 if Resident R25 wanted to be seen by the dentist.

On 7/17/24, at 10:25 AM, Surveyor interviewed Social Worker (SW)-O. SW-O stated that a Resident's consent for dental services is received upon admission. Medical Records (MR)-R is the keeper of the list. MR-R puts a Resident on the list to be receive services and reaches out to the specialists. SW-O states that between nursing and SW-O consents are obtained. Surveyor communicated that Resident R25 has not received dental services since admission and has not been approached about seeing the dentist. SW-O indicated that Resident R25 may have refused services and will look for documentation.

On 7/17/24, at 10:43 AM, MR-R informed Surveyor that MR-R gets an email of who wants to be seen, lets

the specialist know, and does not know if Residents are asked on admission. MR-R has no record of Resident R25 being on the dental list.

On 7/17/24, at 10:48 AM, Surveyor interviewed Resident R25 again and asked if Resident R25 wanted to be seen by the dentist. Resident R25 responded, I have to. I want to be seen by a dentist.

On 7/17/24, at 10:56 AM, Admission Coordinator (AC)-P informed Surveyor that AC-P is responsible for getting admission paperwork signed, but any individual consents are obtained by SW-O. AC-P obtains a signature authorizing physicians such as a dentist to provide dental care.

On 7/17/24, at 3:51 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that Resident R25 was offered to receive dental services since admission. Per NHA-A, we offer the services within 6 months. NHA-A stated there was different leadership prior to May. Surveyor shared there is no documentation that

the need for dental services has been addressed for Resident R25's quality of life.

On 7/18/24, at 3:42 PM, no further documentation was provided that Resident R25 had been offered dental services at admission to address Resident R25's dental concerns. Documentation provided by facility indicates it was first discussed with Resident R25 on 7/17/24, after it was brought to the attention of the facility by Surveyor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 On 7/29/24, at 12:33 PM, Surveyor reviewed additional information provided by the facility after the survey process was completed. Surveyor notes the audit and documentation provided occurred after Surveyor Level of Harm - Minimal harm or brought it to the attention that Resident R25 was not provided the option of dental services. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49845 potential for actual harm Based on observation, interview, and record review the facility did not provide special assistive eating Residents Affected - Few equipment for 1 of 1 sampled resident (Resident R40) reviewed for assistive devices.

Resident R40 did not receive special assistive devices needed for assistance when consuming meals to maintain or improve their ability to eat or drink independently.

Findings include:

Resident R40 was originally admitted to the facility on [DATE REDACTED]. Resident R40's medical diagnosis include: Parkinson's Disease, weakness, protein-calorie malnutrition, and Dysphasia. Surveyor reviewed Resident R40's most recent comprehensive Minimum Data Set (MDS), dated [DATE REDACTED], which documents the following: Resident R40 has a Brief Interview for Mental Status (BIMS) score of 15, which identifies Resident R40 as being cognitively intact. Resident R40 requires partial to moderate assistance with eating.

Resident R40 had a recent prolonged hospitalization from [DATE REDACTED] through 05/10/2024 and was again hospitalized from 5/29/2024 through 06/14/2024.

Surveyor reviewed a document titled: nutrition risk assessment, signed on 6/18/2024, and documents Resident R40's diet order m. (mechanical) soft and is on tube feeding as well. Under Registered Dietitian Review, documents special utensils and cups.

Surveyor noted a Nursing progress note dated 06/17/2024, which documents, writer worked with res on how

she best drinks from a cup i.e by straw or rim of cup. writer observed patient having hard time pulling liquid up from straw, drinking from the rim was better but she needs help holding her cup.

On 07/15/24, at 01:25 PM, Surveyor observed Resident R40 had lunch on the bedside table, untouched. Resident R40 informed Surveyor that Resident R40 asked if someone could help her eat and Resident R40 was told no one was available. Surveyor observed Resident R40 to have very shaky hands. Resident R40 stated it's hard to eat when she is this shaky. Surveyor observed Resident R40 unable to pick up foam cup to drink from straw or use metal fork and knife.

On 07/16/2024, at 10:12 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-LL who informed Surveyor that Resident R40 is a tube feeder. CNA-LL stated Resident R40 is on a regular diet and needs encouragement with eating. CNA-LL informed Surveyor that when Resident R40 is up in a chair Resident R40 can eat independently.

On 07/16/2024, at 11:23 AM, Surveyor interviewed Unit Manager (UM)-AA. UM-AA informed Surveyor that Resident R40 is on a general diet as well as tube feeding at night. UM-AA states Resident R40 will need some assistance, depending on what is being served, something requiring utensils would require more assistance.

On 07/16/2024, at 11:35 AM, Surveyor noted Resident R40's meal ticket documents, needs assist. Surveyor interviewed Dietary Aide (DA)-TT who informed Surveyor that Resident R40 is on a regular diet. DA-TT informed Surveyor that the meal tickets will indicate if a resident is on a mechanical soft, puree or regular diet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 On 07/16/2024, at 11:50 PM, Resident R40's food tray was placed on the bedside table. Surveyor observed metal utensils, a styrofoam cup with a straw, a hamburger bun with breaded meat and cooked carrots. Level of Harm - Minimal harm or potential for actual harm On 07/17/2024, at 10:58 AM, Surveyor interviewed DON-B who informed Surveyor that a CNA or family member will fill out meal request slips for the week. Surveyor inquired what the process is if a resident Residents Affected - Few requires a special diet or eating utensils. DON-B states Speech Therapy will come and give a form to indicate resident needs and they give the form to kitchen dietary aides. DON-B informed Surveyor that she did not see the dietary assessment note about special utensils for Resident R40 until surveyor pointed it out.

On 07/17/2024, at 11:16 AM, Surveyor interviewed Dietician-Q who informed Surveyor that recommendations for special utensils and cups would come from anyone and once a recommendation was made, the expectation is to have those implemented.

On 07/17/2024, at 11:40 AM, Surveyor interviewed Speech Therapist (ST)-UU who informed Surveyor that

she no longer works at the Facility. ST-UU states that in June ST-UU evaluated Resident R40 and Resident R40 was on a mechanical soft diet and was upgraded to a regular diet a couple weeks after readmission.

On 07/18/2024, at 07:57 AM, Surveyor observed Resident R40 up in Resident R40's wheelchair. Resident R40's breakfast tray was on bedside table, LPN-VV assisting Resident R40 with breakfast. Surveyor observed special utensils and cup now provided to Resident R40.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 38829

Residents Affected - Many Based on observation, staff interview, and record review, the facility did not ensure food was stored, prepared and served in a sanitary manner. This practice had the potential to affect 47 of 47 Residents residing in the facility.

*On 7/15/24 and 7/16/24, Surveyor observed Food Service Associate (FSA)-C not wearing a beard net while preparing plates and trays for Residents in the second floor kitchenette.

*On 7/15/24 and 7/16/24, Surveyor observed the facility's low temperature dish machine not reach the minimum required temperature of 120 F and Food Service Aide (FSA)-C, FSA-D, and FSA-E all stated they do not use test strips to test the sanitizer solution concentration (50-100ppm-parts per million sodium solution hypochlorite [chlorine]), thus not ensuring proper sanitation.

Findings Include:

The facility's policy Sanitation and Infection Prevention/Control; Dish Machine Temperatures Issued 5/95, and Last Revised on 1/24 documents:

.:Policies:

Dishmachine wash and rinse water should be maintained at temperatures that meet the guidelines established by the Food and Drug Administration. *State or local regulations will apply if stricter.

Low Temperature Machine:

-Wash Temperature 120 F

-Final Rinse Sanitizer Solution Concentration-50-100 ppm(parts per million sodium solution hypochlorite(chlorine) on the dish surface in final rinse(less than 100F) .

The facility's policy Sanitation and Infection Prevention/Control; Dish Machine Temperatures Issued 5/95, and Last Revised on 1/24 documents:

.Procedures:

Supervisor/Food and Nutrition Associate as assigned

-Low Temperature Dishmachine-record on Dishmachine Temperature Record form:

-Wash temperature during each period of use.

-Final rinse sanitizer concentration during each period of use

Supervisor

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 -If documentation of the temperatures and test strips/max temps results has been assigned to a Food and Nutrition Associate, confirms that it is completed at each meal period. Level of Harm - Minimal harm or potential for actual harm Director

Residents Affected - Many -Makes management decision concerning adequacy of sanitation of service ware. If due to inappropriate concentration of sanitizer solution(low temperature machine), implements disposable service ware.

Director/Designee

-Verifies completion of logs; initials form weekly.

The facility's policy Orientation and Education, Uniform Dress Code Issued 5/95 and last Revised on 1/23 documents:

.Associates Working with Food

-Wear the approved hair restraint when on duty regardless of length or presence of hair.

-Restrain all facial hair with a beard net/restraint.

On 7/15/24, at 11:05 AM, Surveyor observed Food Service Associate (FSA)-C in the kitchenette on the 2nd floor wearing a hairnet while taking temperatures of the ready to serve food items for lunch, but was not wearing a beard net. FSA-C has an evident beard.

On 7/15/24, at 11:29 AM, Surveyor observed FSA-C in the 2nd floor kitchenette, placing the lunch items on Resident plates. FSA-C was wearing a hairnet but was not wearing a beard net.

On 7/15/24, at 12:26 PM, Surveyor confirmed with Food Service Supervisor (FSS)-F that the dish washer in

the 2nd floor kitchenette was a low temperature dish machine. Surveyor observed FSA-C rinse off the dishes and place in the dish machine. Surveyor observed the wash cycle which started at 113, went down to 111 and back up to 112. FSA-C informed Surveyor that for the dishes to be completely sanitized, the temperature should be at 110. FSA-C did not do a test strip after the cycle.

On 7/15/24, at 12:35 PM, Surveyor requested the manufacturer guidelines for the dish machine from FSS-F.

On 7/16/24, at 7:50 AM, Surveyor observed FSA-C preparing trays in the 2nd floor kitchenette and is wearing a hair net but not a beard net.

On 7/16/24, at 12:45 PM, Surveyor observed FSA-C run the dish machine. Surveyor observed the temperature starting at 121 and went immediately down to 110 and held at that temperature during the whole cycle. Surveyor did not observe FSA-C test the chemicals. Surveyor asked FSA-C, if FSA-C checks the chemicals after washing dishes with each meal. FSA-C stated FSA-C usually does not use the test trips. Surveyor asked if there were test strips in the 2nd floor kitchenette. FSA-C had to dig for the test strips which were located at the back of the drawer. FSA-C completed the test strip and stated it read 200 ppm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On 7/16/24, at 12:56 PM, Surveyor observed FSA-D unloading the dish machine up in the 3rd floor kitchenette. Surveyor asked if FSA-D and FSA-E who was also present if both FSA-D and FSA-E use the Level of Harm - Minimal harm or test strips for each meal. Both FSA-D and FSA-E stated they did not use the test strips and were unable to potential for actual harm locate test strips in the kitchenette at this time.

Residents Affected - Many Surveyor reviewed the dish machine logs for May, June, and July 2024 for both 2nd and 3rd floor kitchenettes.

2nd Floor temperatures recorded for May and June only documents 38 meals where the dish machine reached the minimum of 120 F per policy for 30 days of 3 meals a day. July's recorded temperatures has no minimum temperatures of 120 F recorded for any meal. Surveyor notes the chlorine rinse (50-100 ppm) is recorded as 100 ppm for just about every meal, everyday, every month.

3rd Floor temperatures recorded for May and June only documents 3 meals where the dish machine reached

the minimum of 120 F per policy for 30 days of 3 meals a day. July's recorded temperatures has 3 recorded temperatures of minimum temperature of 120F recorded for any meal. Surveyor notes the chlorine rinse (50-100 ppm) is recorded as 100 ppm for just about every meal, everyday, every month.

Surveyor notes there is a section on the Dishmachine Temperature Record for the Manager Weekly Review and this section is completely blank for all 3 months.

On 7/17/24, at 8:16 AM, FSS-F confirmed that FSA-C should have been wearing a beard net while serving food onto the plates and preparing Resident trays. FSS-F stated that test strips should be done with every meal. Surveyor shared the concern that FSA-C, FSA-D, and FSA-E confirmed they have not been using the test strips and shared the same ppm number is being repeated every day on the dish machine logs. Surveyor also shared that there is no manager weekly review signature on the log, indicating that the temperature and chemical readings were not being audited on a weekly basis as the log indicates should be completed.

The manufacturers operation manual for the low temperature dish machine issued 5/15/10 documents the wash and sanitizing rinse should be at a minimum of 140 F.

On 6/25/24, the representative tested the dish machines for optimal efficiency. 108F is recorded for the 2nd floor and 121F is recorded for the 3rd floor.

On 7/17/24, at 3:42 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A the concern that FSA-C was not wearing a beard net during the survey process and the concern with the dish machines temperature not reaching minimum required temperature per dish machine manufacturers recommendations. Surveyor also shared that Food Service Associates have not been using the test strips to test the chemicals. No further information was provided by the facility at this time in regards to beard nets not being worn and

the low temperature of the dish machines and not using the chemical test strips to test the ppm.

Surveyor notes that FSS-F conducted a re-education on 7/17/24 with all food service associates on the topics of dish machine temperatures and test strips and hair/beard restraint guidelines.

On 7/18/24, at 8:23 AM, Surveyor left a message for the dish machine representative for the facility but did not receive a phone call back during the survey process.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On 7/22/24, at 11:42 AM, FSS-F informed Surveyor that the representative came to the facility late afternoon

on 7/16/24 to check the temperature of both dish machines and adjusted to increase the temperature of both Level of Harm - Minimal harm or dish machines after Surveyor had observed the low temperatures during the wash of dishes on 7/15/24 and potential for actual harm 7/16/24. Surveyor notes that 2nd floor dish machine is now at 135 and 3rd floor is now at 137. FSS-F and Surveyor discussed the discrepancy in required minimum temperature for the dish machines. Surveyor Residents Affected - Many pointed out that the low temperature dish machine manual states 140F, but the facility policy is 120F. FSS-F will confirm with the dish machine representative if it should be 140F or 120F. Surveyor notes per regulation

it is 120F for wash and 50ppm for the final rinse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20483

Residents Affected - Few Based on interview and record review the Facility did not ensure hospice services were coordinated for 2 (Resident R5 & Resident R29) of 2 residents reviewed for hospice.

* Hospice visit notes were not kept in Resident R5's medical record or in Resident R5's hospice binder which was located in the nurses station.

* Resident R29's recertification was not complete and there was not list of assigned staff from hospice with contact information.

There is not a designated facility liaison with hospice.

Findings include:

The facility's policy titled, Hospice Program last revised 12/2017 under Policy Interpretation and Implementation documents:

D. When a resident participates in the hospice program, a coordinated plan of care between the community, hospice agency and resident/representative will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status.

1.) Resident R5 was admitted to the facility on [DATE REDACTED] with diagnoses which include multiple sclerosis, cirrhosis of the liver, unspecified protein calorie malnutrition, hypertension, anxiety disorder, and depression.

The physician orders dated 9/18/23 documents Hospice Eval (evaluation) and treat.

The hospice care plan initiated 9/25/23 documents the following approaches all dated 9/25/23:

* Hospice referral and services through [Name] hospice services

* Hospice nurse visits as scheduled times per week with PRN visits

* Hospice social worker and hospice chaplain visits as scheduled and PRN

* Hospice volunteer visits as indicated

* Monitor for pain or symptoms of distress or anxiety and notify hospice nurse or physician

* Administer medications for comfort as indicated and as ordered. Monitor for effectiveness and observe for side effects and inform physician PRN (as needed)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 * Hospice CNA (Certified Nursing Assistant) will visit as scheduled and provide bathing and ADL (activities daily living) (activities daily living) care Level of Harm - Minimal harm or potential for actual harm * Staff will consult with hospice nurse with change of condition or pain management needs

Residents Affected - Few * Include family in care and in plan of car and offer support services PRN

* Position for comfort in bed or chair as client desires.

The significant change MDS (minimum data set) with an assessment reference of 9/29/23 has a BIMS (brief

interview mental status) score of 15 which indicates cognitively intact. Resident R5 is assessed as requiring extensive assistance with two plus person physical assist for bed mobility & transfers, does not ambulate and requires extensive assistance with one person physical assist for toileting. Resident R5 is assessed as being occasionally incontinent of urine and always incontinent of bowel. Resident R5 is checked for hospice care.

On 7/18/24, at 7:09 a.m., Surveyor asked RN/UM (Registered Nurse/Unit Manager)-AA if she knows who is

the facility's hospice liaison. RN/UM-AA replied I don't know [NHA-A's first name] may have a better idea.

On 7/18/24, at 9:22 a.m., Surveyor reviewed Resident R5's hospice binder which was located in the nurses station. Surveyor noted inside Resident R5's hospice binder includes interdisciplinary plan of care revision/physician orders and also has a log of visit description which includes the date, employee name, discipline and visit type. Surveyor was unable to locate hospice visit notes in the hospice binder. Surveyor also reviewed Resident R5's medical record and was unable to locate any hospice visit notes

On 7/18/24, at 9:27 a.m., Surveyor asked CNA-DD if she knows when hospice staff comes in for Resident R5. CNA-DD replied I don't know the exact day but when they do come I encourage her to do her cares.

On 7/18/24, at 9:29 a.m., Surveyor asked RN (Registered Nurse)-JJ if she knows when hospice staff come in for Resident R5. RN-JJ replied not since [Name] stopped coming, she used to come in Monday, Wednesday and Friday. I didn't see anyone yesterday and I was here until 6:00 p.m. and no one was here home. RN-JJ informed Surveyor there's another case manager but she doesn't know the name. Surveyor asked RN-JJ if

she knows who is the facility's hospice liaison. RN-JJ replied I have no clue.

On 7/18/24, at 9:40 a.m., Surveyor asked RN/UM-AA if she knows when hospice staff come in for Resident R5. RN/UM-AA informed Surveyor their typical schedule is Monday, Wednesday & Friday. Surveyor asked RN/UM-AA who Resident R5's hospice case manager is. RN/UM-AA informed Surveyor she has it written down and stated she usually works with the nurse, [Name]. Surveyor informed RN/UM-AA Surveyor was informed this hospice nurse is not at the facility any longer. RN/UM-AA indicated she was unaware of this. Surveyor informed RN/UM-AA Surveyor was unable to locate any hospice visit notes for Resident R5 and asked if hospice leaves their notes. RN/UM-AA informed Surveyor this is something they are working with hospice on as they don't always leave their notes. RN/UM-AA informed Surveyor this is something she's been noticing and she has a call out to hospice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 On 7/18/24, at 10:35 a.m., Surveyor asked DON (Director of Nursing)-B if she knows who is the facility's hospice liaison. DON-B replied no ma'am I sure don't. Surveyor asked if hospice leaves their notes. DON-B Level of Harm - Minimal harm or replied I'm going to be honest with you I saw a note for the first time yesterday with [name of Unit potential for actual harm Manager-J]. I don't know if they leave their notes or who they leave them with. Surveyor informed DON-B Surveyor has been unable to locate Resident R5' hospice visit notes. DON-B informed Surveyor they need to know Residents Affected - Few when they came into the building and if they gave a shower. DON-B informed Surveyor she doesn't like the process and will be changing it.

On 7/18/24, at 4:06 p.m., during the end of the day meeting NHA (Nursing Home Administrator)-A was informed of the above. No additional information was provided to Surveyor regarding Resident R5's hospice visit notes.

38829

2.) Resident R29 was admitted to the facility on [DATE REDACTED] with diagnoses of Heart Failure, Anemia, Unspecified Dementia and Anxiety Disorder. Resident R29 has an activated Health Care Power of Attorney (HCPOA) effective 9/16/2019. Resident R29 has been receiving hospice service since 4/24/23.

Resident R29's Annual MDS dated [DATE REDACTED] documents Resident R29 has short and long term memory impairment and demonstrates severely impaired skills for daily decision making. Resident R29's MDS also documents that Resident R29 is at risk for developing skin issues and has no current skin issues, osteoporosis is not documented as a current diagnosis, Resident R29 is receiving scheduled pain medications and that a pain interview can be completed but then is documented that Resident R29 is unable to answer any questions. Resident R29's documents Resident R29 has range of motion impairment on both upper and lower extremities on both sides and that Resident R29 is dependent for assistance for eating, hygiene, mobility, and transfers.

Surveyor reviewed Resident R29's current physician orders as of 7/16/24 and notes there is no physician order to evaluate and treat for hospice.

On 7/16/24, at 10:27 AM, Surveyor reviewed Resident R29's hospice binder located at the nurse's station. The last recertification of terminal illness in the binder is dated 6/23/23-8/1/23. There is no list of assigned hospice staff with contact information for Resident R29 and no schedule of when hospice staff will be in the facility providing cares to Resident R29.

On 7/16/24, at 10:29 AM, Licensed Practical Nurse (LPN)-M states there is no actual schedule of when hospice staff is arriving, and agreed contact information is not available but stated the nurse will text my phone when coming into the facility.

On 7/16/24, at 10:43 AM, Surveyor interviewed Hospice Registered Nurse (HRN)-S. HRN-S confirmed HRN-S is Resident R29's primary hospice nurse. HRN-S was not aware a list of hospice staff and contact information and a schedule of hospice caregivers should be easily accessible to facility staff.

On 7/17/24, at 12:26 PM, Surveyor interviewed Unit Manager (UM)-J who stated UM-J is not aware of a specific named person in the facility that is the liaison between the facility and hospice.

On 7/17/24, at 3:36 PM, Hospice Supervisor (HS)-V informed Surveyor that the facility has never communicated who the liaison is at the facility to communicate issues to in regards to Resident R29.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 On 7/18/24, at 10:37 AM, HRN-S was interviewed again by Surveyor who stated some facility nurses want to given verbal report and HRN-S always writes out a communication form on Resident R29 as well. UM-J stated to put Level of Harm - Minimal harm or the communication form in a box in the nurses station. HRN-S stated the written communication forms were potential for actual harm not always getting into Resident R29's hospice binder so HRN-S started placing the written communication forms directly into Resident R29's hospice binder. HRN-S confirmed there have been multiple times where HRN-S has Residents Affected - Few communicated to facility nurses in regards to care issues or changes of care with Resident R29 that has not been addressed by facility nursing staff timely or not at all.

On 7/18/24, at 12:52 PM, Director of Nursing (DON)-B stated there is no determined contact person from the facility for hospice to communicate with in regards to Resident R29.

On 7/18/24, at 3:42 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that the coordination of care between the facility and hospice for Resident R29 is indicative of a communication failure as well as the facility not designating one specific contact person with clinical background to be the contact person for hospice to communicate with in order to maintain quality of life for Resident R29. No further information was provided by the facility at this time.

Surveyor reviewed he Nursing Facility Services Agreement between the facility and the hospice provider for Resident R29. The contract was entered into on 6/10/19 and signed 6/13/19. The following documents:

.Article 1

Facility Obligations

Facility shall ensure that individuals who have elected, directly or through such individuals' legal representatives, to receive services from hospice and who are accepted by hospice to receive such services are kept comfortable, clean, well groomed and protected from negligent and intentional harm including, but not limited to, accident injury and infection.

Facility's primary responsibility is to provide personal care including the following, but not limited to,

(iv) assisting in the administration of medicine

(vi) supervising and assisting in the use of any durable medical equipment and therapies

(viii) providing health monitoring of general conditions

(ix) contacting family/legal representatives for purposes unrelated to a hospice terminal condition

1.4 Plan of Care. Facility will work with hospice to develop a written care plan for each hospice patient that is established, maintained, reviewed, and modified.

1.15 Authorized Facility Representatives. Facility shall designate its administrator or another qualified individual, as a liaison to represent facility and to implement the provisions of this agreement. Facility shall also designate a clinically-trained member of the facility's interdisciplinary team to work with hospice representatives to coordinate care provided by facility and hospice to hospice patients.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Article 2

Level of Harm - Minimal harm or Hospice Obligations potential for actual harm 2.6 Provision of Information Hospice shall promote open and frequent communication with facility and shall Residents Affected - Few provide facility with sufficient information to ensure that the provision of services by facility under this agreement is in accordance with hospice patient's plan of care, assessments, treatment planning and care coordination

c. Certifications. Physician certifications and recertification of terminal illness

d. Contact Information. Names and contact information for hospice personnel involved in providing hospice services

e. On-Call System. Instructions on how to access hospice's 24-hour on-call system

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49845 potential for actual harm Based on observations, interviews and record review, the facility did not establish and maintain an infection Residents Affected - Many prevention and control program based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 47 residents.

The facility's Water Management Plan (WMP) was not based on current standards of practice and did not:

~Reflect changes in program members.

~Include the Facility's Infection Preventionist (IP).

~revise WMP control measures after the closure of wing 1

~have a defined flush program for little used outlets.

~have logs to monitor water temperatures.

~ include eye washing stations and ice machines in risk assessment.

~measure and record residual (free) disinfectant (Chlorine) levels.

The Facility's Surveillance of the Infection and Control Program did not have:

~ a defined policy and procedure for staff illness.

~ a list of reportable communicable diseases.

~ a system for addressing increase infection rates and the corrective actions taken by the facility.

~urinary tract infections (UTI) separated into catheter associated and non-catheter associated UTIs.

~ have complete COVID outbreak investigation

It was observed that the Facility did not:

~wear proper personal protective equipment for a resident on Enhanced Barrier Precautions.

~have a privacy bag over a residents' urinary catheter bag and ensure it was handles in a hygienic manner by not placing on the floor.

Findings include:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Water Management Program

Level of Harm - Minimal harm or 1.) The 6/24/21 CDC Toolkit titled, Developing a Water Management Program to Reduce Legionella Growth potential for actual harm & Spread in Buildings identifies the key elements of a water management program for healthcare facilities to include: Residents Affected - Many 1. Establish a water management program team

2. Describe the building water systems using text and flow diagrams

3. Identify areas where Legionella could grow and spread

4. Decide where control measures should be applied and how to monitor them

5. Establish ways to intervene when control limits are not met

6. Make sure the program is running as designed and is effective

7. Document and communicate all the activities

The 6/24/21 CDC Toolkit documents, program team members should possess certain skills that are needed to develop and implement your water management program. The team should also include:

-Someone who understands accreditation standards and licensing requirements

-Someone with expertise in infection prevention

-A clinician with expertise in infectious diseases

-Risk and quality management staff

The CDC toolkit identifies locations in a buildings water system where Legionella can grow and spread to include but not limited to:

~Hot and cold-water storage tanks

~Water heaters

~Water Filters

~Electronic and manual faucets

~Aerators

~Shower heads and hoses

~Pipes, valves, and fittings

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 ~Infrequently used equipment including eye wash stations.

Level of Harm - Minimal harm or ~Ice machines potential for actual harm ~Hot tubs Residents Affected - Many Control Measures: Determine Locations Where control measures must be applied and maintained to stay in established control limits.

The CDC toolkit identifies factors internal to buildings that can lead to Legionella growth to include:

~Water temperature fluctuations: Provides conditions where Legionella grows best (77 -108 Fahrenheit (F))

~Water pressure changes

~PH (measurement of acidity or alkalinity of a solution on a scale 0 to 14)

~Inadequate disinfectant: Does not kill or inactivate Legionella

~Water stagnation: Encourages biofilm growth and reduces temperature and levels of disinfectant. Common issues that contribute to water stagnation include renovations that lead to 'dead legs' and reduced building occupancy.

The Wisconsin State Plumbing Code, Chapter SPS 382.50(3)(b)6, requires a nursing homes hot water system to be installed and maintained to provide bacterial control by one of the following methods:

~Water stored and circulation initiated at a minimum of 140 F and with a return of a minimum of 124 F. This standard is best practice even considering the facility was built prior to May 2003 and grandfathered to meet requirement.

~ 5mg/L residual chlorine.

~Another disinfection system approved by the department.

The Facility's policy, titled: Water Management Program to reduce Legionella exposure, with a last approved date of 01/2024, documents in part: B. The community water management plan shall include: 1. Conducting

a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria and fungi) could grow and spread in the facility water system. 2. Implementing a water management program that considers the ASHRAE industry standard and the CDC toolkit and includes control measures such as physical controls temperature management disinfectant level control visual inspections and environmental testing for pathogens. 3. Specifying testing protocols and acceptable ranges for control measures and documenting the results of testing and corrective actions taken when control limits are not maintained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Surveyor reviewed the Facility's WMP, dated March 01, 2024, which documents in part: Requirements: this water management plan will conform to the steps below outlining the elements of a water management Level of Harm - Minimal harm or program. Program team-identify persons responsible for program development and implementation. Control potential for actual harm measures-determine locations where control measures must be applied and maintained in order to stay with established control limits. Monitoring/corrective actions- establish procedures for monitoring whether control Residents Affected - Many measures are operating within established limits and, if not, take corrective actions. Confirmation-established procedures to confirm that the program is being implemented as designed (verification) and the program effectively controls the hazardous conditions throughout the building water systems (validation). Documentation-establish documentation and communication procedures for all activities of the program

Per the Facility's WMP program team consists of The Executive Director and the Facility Manager. The executive Director listed in the Facility's WMP is the former Executive Director and is no longer employed at

the Facility.

Surveyor reviewed the Facility's flow diagram of the Facility's water system. Surveyor noted that the Facility's description of cold water distribution documents: cold water is routed to the ice machine, kitchen, laundry, resident faucets in showers along with the domestic hot water system. Surveyor reviewed the process flow diagram and noted the Facility's ice machine(s) is not listed.

Surveyor reviewed the Facility's control measure, titled Hot Water Systems documents in part: Risk Factor: Water Heater Control measure: Check flow and return temperatures at hot water heater Frequency: monthly or as required or recommended by Authority Having Jurisdiction (AHJ) or your water treatment professional. Monitoring: supply temperature should be checked at the outlet of the hot water heater and should not be lower than 140 F. The return temperature should also be checked monthly and should not be lower than 122 F.

Surveyor reviewed the facility's maintenance task log Titled, Water Systems which documents in part, Water Heaters-Monthly Task One and noted no documented water temperatures from 07/03/2023 to 07/10/2024.

Surveyor reviewed the Facility's control measure, titled Hot Water Systems which documents in part: Risk Factor: Water Heater Control measure: check water temperature at the end of each return leg at time of no hot water use. Frequency: monthly or as required or recommended by AHJ or your water treatment professional. Monitoring: ensure temperature is at a minimum of 122 F.

Surveyor reviewed the facility's maintenance task log Titled, Water Systems: Water Heaters-Monthly Task Two and noted no documented water temperatures from 07/03/2023 to 07/10/2024.

Surveyor reviewed the facility's control measure Titled, Hot Water Systems which documents in part: Risk Factor: Water Heater Control Measure: check temperatures after 30 seconds and 60 seconds of running at all taps to ensure that you are receiving the appropriate temperature and it being achieved in a reasonable amount of time. Frequency: annually or as required or recommended by AHJ or your water treatment professional. Monitoring: ensure the temperature is at a minimum of 122 F

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 94 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Surveyor reviewed the facility's maintenance task log Titled, Water Systems: Water Heaters-Monthly Task Two which documents in part: Control Measure Check Temperatures after 30 seconds of running at all taps. Level of Harm - Minimal harm or Surveyor noted no documented water temperature and no documentation for running of all taps for 60 potential for actual harm seconds.

Residents Affected - Many Surveyor reviewed the facility's control measure Titled, Hot & Cold Water Systems which documents in part: Risk Factor: Little-Used Outlets Control Measure Flush little used outlets. Flush for several minutes and until temperature stabilizes and is comparable to supply water. Have a flush program defined in the Water Management Plan by the team. Location: Thru out building Frequency: twice weekly where users are at high risk; weekly in all other buildings.

Surveyor reviewed the facility's maintenance task log Titled, Little Used Outlets which documents in part: Control Measure Task Flush little-used outlets. Flush for several minutes and until temperature stabilizes and is comparable to supply water. Have a flush program defined in the Water Management Plan by the team. Surveyor noted task was documented as completed one time per week from 03/2024 to current. Surveyor also noted the wing 1 of the facility has been closed since 03/2024, per NHA-A and noted there is no defined flush program in the Facility's WMP.

Surveyor reviewed the facility's control measure Titled, Hot & Cold Water Systems which documents in part: Risk Factor: Check for Residual (free) Disinfectant (Chlorine) Levels Control Measure: Measure and record Residual (free) Disinfectant (Chlorine) levels on the incoming city water supply as well as a representative most distal location within the facility. Frequency: Weekly. Surveyor noted, no maintenance task log provided for this control measure.

Surveyor received a Maintenance Task log titled: Inspect eyewash stations. Surveyor noted this task is not identified in the facility's WMP. Steps included in the task log are documented as:

-verify the flow of water begins in one second or less.

-verify the water flow is continuous by activating the unit.

-run water for three minutes to flush system impurities.

-verify that water flow continues and the water temperature is between 60 F and 100 F.

-verify that eye wash station are disinfected weekly.

Surveyor noted, from 07/2023 through 07/2024 the task was documented as completed once per month.

Additionally, surveyor reviewed the facility's prior WMP, dated 02/28/2023, and noted no notable revisions to

the Facility's current WMP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 95 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 07/18/24 at 11:28 AM, Surveyor interviewed Facility Director-X who stated he is in charge of the WMP and the IP is not involved in the WMP. Facility Director-X stated the WMP is revised annually or when there Level of Harm - Minimal harm or is a change to water lines. Facility Director-X stated wing 1 rooms are shut down. Facility Director-X stated potential for actual harm the sinks and toilets are flushed daily. Facility Director-X informed Surveyor that temperatures of water are not logged and are just documented as yes meets the temp range. Facility Director-X stated the Facility does Residents Affected - Many have eyewash stations that are part of maintenance program tasks. Facility Director-X informed Surveyor that a company comes in and cleans ice machines. Facility Director-X was not aware of a chlorine test needing to be performed. Facility Director-X stated the Executive Director listed on the WMP is the former Executive Director and is no longer at the Facility.

On 07/18/24 at 10:09 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A states the IP should be listed in the WMP and everyone that is in QAPI (Quality Assurance and Performance Improvement) is part of water management committee.

Infection Surveillance

2.) The Facility does not have a policy for staff illness procedures.

The Facility's policy, titled: Surveillance for Infections documents in part, Policy Statement The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiological significant infections that have substantial impact on potential resident outcome and that may require transmission based precautions and other preventative interventions. H. The charge nurse will notify the attending health care provider and the Infection Preventionist of suspected infections. 1. The infection preventionist will determine if the infection is reportable. Data Collecting and Recording A. For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate: 8. Treatment measures and precautions (interventions and steps taken that may reduce risk.) . D. For targeted surveillance using the community-created tools, follow these guidelines: 3. MONTHLY: Summarize monthly data for each nursing unit by site and by pathogen.

Surveyor reviewed the Facility's infection surveillance for 04/2024 through 06/2024 and noted no identified increase in infection rates or interventions implemented. Surveyor noted an increase in infection rates from 05/2024 to 06/2024. The surveillance data did not have organism type or urinary tract infections (UTI) separated by catheter associated and non-catheter associated infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 07/17/24 at 02:02 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B stated she began working at the Facility in 04/2024 and became the IP in 05/2024. DON-B stated Licensed Practical Nurse Level of Harm - Minimal harm or (LPN)-Y assists her with the Facility's infection control program (ICP). DON-B informed Surveyor that any potential for actual harm resident with a nasogastric tube, wound, foley catheter or multidrug resistant organism (MDRO) would require Enhanced Barrier Precautions (EBP). DON-B stated gloves, gown and mask are required when Residents Affected - Many performing direct cares of a resident on EBP. DON-B stated they meet during morning huddle in the morning and discuss which residents are on EBP or other transmission-based precautions (TBP). DON-B stated she would need to get a list of the reportable communicable diseases and get back to Surveyor with that information. DON-B stated that NHA-A would have information regarding staff testing. Surveyor asked DON-B to explain the Facility's procedure regarding staff illness. DON-B stated the staff would need to let the DON, NHA and managers know if they have signs and symptoms. DON-B stated staff is informed not to come to work if symptomatic. DON-B stated staff would have to see a doctor and get a note to return to work until staff is fever free, symptom free, temperature less than 100 F without medication for 24 hours and no nausea or vomiting. If at work, staff immediately sent home, can test at facility but would still need a doctor note to return.

On 07/18/24, at 10:14 AM, Surveyor interviewed NHA-A. Surveyor asked NH-A the procedure for staff illness. NHA-A stated, staff is to call supervisor and give symptoms. NHA-A stated, depending on symptoms,

a covid test can be obtained at the Facility. If calling in for other issues staff would need to a release back to work from doctor. Information regarding staff illness is only documented on the schedule for call-ins to keep track of attendance, per NHA-A. NHA-A stated last week Dietician-Q tested positive for COVID, which prompted them to test all residents. NHA-A was not able to provide documentation where this is documented for surveillance purposes.

On 07/18/24, at 10:20 AM, Surveyor interviewed LPN-Y. Surveyor observed LPN-Y going through infection control logs. LPN-Y stated she is currently reviewing logs from 04/2024 forward to ensure everything is in there. LPN-Y stated she collects data and inputs information for DON-B regarding the ICP.

On 07/18/24, at 02:29 PM, Surveyor interviewed DON-B. Surveyor inquired how DON-B acquires the infection percentage rates. DON-B stated she gets the calculations by in-putting information into infection log

in Matrix. DON-B stated she looks at infection rates monthly. DON-B stated if an increase in infection rates is observed, then they will educate staff as well as residents, observe cares, bring it to QAPI and discuss in daily huddles. DON-B stated she is working on putting together, and improving the track and trending/surveillance of the ICP.

Surveyor noted an increase in UTI infection rates from 05/2024 to 06/2024. No documentation provided on

this increase being addressed or interventions implemented.

On 07/22/24, at 11:06 AM, Surveyor reviewed QAPI documentation from 05/2024-06/2024. Surveyor noted no information documented regarding acknowledgment of increase in UTI infections and no documented interventions implemented to address this increase.

COVID outbreak

3.) Surveyor reviewed the facility's infection control surveillance and noted the facility documented a COVID outbreak that began on 01/09/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The Facility's policy, titled: Outbreak of Communicable Diseases, with a last approved date of 01/2024, documents in part: Policy Interpretation and Implementation . G. The administrator will be responsible for: 1. Level of Harm - Minimal harm or Telephoning a report to the health department;2. Restricting admissions to the community as indicated or as potential for actual harm authorized by the health department medical director; 3. Submitting periodic progress reports to the health department, as requested; 4. Calling emergency meetings of the infection control committee; 5. Residents Affected - Many Discontinuing group activities, as indicated; 6. Limiting visitors if indicated(i.e., influenza in the community); and 7. Forwarding communicable disease report cards to the health department, as required.

On 07/22/2024, at 08:33 AM, NHA-A gave Surveyor paperwork from the COVID outbreak that contained all staff/residents COVID testing, and the education provided to staff on hand hygiene & personal protective equipment (PPE). NHA-A states he will have to reach out to the person who did the investigation, and states

he provided what he had.

On 07/22/24, at 11:19 AM, A summary of the COVID outbreak was provided to Surveyor by NHA-A.

Per the facility summary, titled: COVID outbreak 2024, documents the outbreak began on 01/09/2024 with two residents on the second floor. Two residents were treated prophylactically, one with Paxlovid and one with Molnupiravir. All COVID positive staff members and residents were not hospitalized and had no complications related to COVID. All residents on the 2nd floor were tested two times per week and no further cases were reported. All staff members were required to mask throughout the building and test biweekly as well. The Milwaukee County health department was contacted on 01/16/2024 alerting of current COVID outbreak. The last resident came out of isolation on 01/24/2024. Biweekly testing to continue for 14 days since the last resident was removed off isolation with a tentative date to be completed on 02/07/2024. On 01/26/2024 residents on the third floor started experiencing symptoms. The facility continued biweekly testing. On 02/03/2024 all staff members were asymptomatic and were able to return to work. On 02/06/2024 all remaining residents were removed from isolation and asymptomatic. Rooms were terminally cleaned, biweekly testing and building wide masking to continue for at least 14 days from last resident removed from isolation. All staff members were using required PPE to enter COVID positive resident rooms with gown, gloves, goggles and N95. Proper signage and isolation carts were placed outside of designated rooms.

Surveyor noted no documentation of Milwaukee County Health Department recommendations, no restriction of admissions, no documentation of emergency meeting with infection control committee (ICC), no documentation of discontinuing/limiting group activities, no documentation of limiting of visitors and no documentation of forwarding communicable disease report cards to the health department as required, per

the Facility Policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 98 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 07/22/24, at 2:30 PM, Surveyor spoke with Corporate IP-Z. Corporate IP-Z stated she is the Director of clinical reimbursement but also has IP certificate. Corporate IP-Z stated her role is to support the community Level of Harm - Minimal harm or in the Facility with MDS (minimum data set) but also with clinical questions as needed. Corporate IP-Z stated potential for actual harm she tries to visit the facility weekly to look at the Facility's ICP. Corporate IP-Z stated she was at the Facility

on 07/21/2024 to review ICP. Prior to 07/21/2024 she was at the Facility on 06/20/2024 and reviewed the Residents Affected - Many ICP. Corporate IP-Z stated she does not normally work on infection surveillance with DON-B, but instead embrace the Matrix software for rates. Corporate IP-Z stated data is collected by making rounds, talking with staff, observing cares, and then that information is put into data software. Surveyor asked Corporate IP-Z if organisms should be listed on surveillance. Corporate IP-Z stated the team on site is new to using the infection tracking but are aware of the organisms. Surveyor asked Corporate IP-Z about UTI categories being identified by catheter associated infections and non-catheter associated infections. Corporate IP-Z stated it's a small facility, the team knows who has catheters and who does not. Surveyor asked Corporate IP-Z if there is an increase in infection rates would that be documented in QAPI. Corporate IP-Z stated yes, minuets should be taken during QAPI meetings.

no further information was provided during time of survey.

20483

Enhanced Barrier Precautions

4.) The facility's policy titled, Enhanced Barrier Precautions last revised 3/24 under Purpose #4 documents Enhanced Barrier Precautions expand the use of PPE (personal protective equipment) and refer to the use of gown and gloves during high-contact resident activities that provide opportunities for transfer of MDRO (multidrug-resistant organism) to staff hands and clothing.

Surveyor was provided with the facility's policy titled, Procedure: Handwashing/Hand Hygiene last revised 5/18 which documents how to perform washing hands/hand hygiene but does not address when to perform handwashing/hand hygiene.

* Resident R5's diagnoses include multiple sclerosis, cirrhosis of the liver, unspecified protein calorie malnutrition, hypertension, anxiety disorder, and depression.

Resident R5 has a Stage 3 pressure injury on the left upper buttocks and is EBP (enhanced barrier precautions).

The significant change MDS (minimum data set) with an assessment reference date of 9/29/23 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. Resident R5 is assessed as requiring extensive assistance with two plus person physical assist for bed mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 99 of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 7/16/24, at 11:39 a.m., Surveyor observed CNA (Certified Nursing Assistant)-KK and CNA-LL enter Resident R5's room and place gloves on. Surveyor observed neither CNA-KK or CNA-LL are wearing a gown. CNA-KK & Level of Harm - Minimal harm or CNA-LL removed pillows from under Resident R5 and then reposition Resident R5 up in bed. CNA-KK asked Resident R5 how's that. Resident R5 potential for actual harm then directed CNA-KK & CNA-LL where she wanted the pillows under her including the left & right side, under Resident R5's left shoulder/arm area and under Resident R5's lower legs. CNA-KK placed a second pillow under Resident R5's Residents Affected - Many upper left side. The call light was placed in reach, Resident R5's purse was placed on the bed along the left side and

the head of the bed elevated. CNA-LL removed her gloves and left Resident R5's room. Surveyor observed CNA-LL did not perform hand hygiene prior to leaving Resident R5's room. CNA-KK removed her gloves, cleansed her hands and left Resident R5's room.

Surveyor noted Resident R5 is on enhanced barrier precaution and CNA-LL & CNA-KK did not wear the appropriate PPE (personal protective equipment).

On 7/18/24, at 7:12 a.m., Surveyor observed CNA-DD place a gown on. Surveyor asked CNA-DD for residents on enhanced barrier precautions do you always wear a gown. CNA-DD replied yes. CNA-DD placed a mask on cleansed her hands, placed gloves on, and informed Resident R5 name of RN (Registered Nurse)-JJ wants me to wash you up. CNA-DD wet wash cloths, asked Resident R5 if she wants to change her shirt today, lowered the head of the bed and removed the pillows from under Resident R5. CNA-DD unfastened Resident R5's incontinence product and then washed Resident R5's face.

At 7:16 a.m. RN-JJ entered Resident R5's room with treatment supplies. CNA-DD lowered Resident R5's incontinence product, squeezed water on Resident R5's frontal perineal area and washed the frontal area. CNA-DD informed Resident R5 she was going to roll her on her side and Resident R5 was positioned on left side. CNA-DD wiped Resident R5's rectal area to remove BM (bowel movement) stating to Resident R5 I think you need to have a BM my friend. CNA-DD removed the incontinence product, placed the wash cloth inside the product and threw the product away. CNA-DD did not remove her gloves or perform hand hygiene. CNA-DD unfolded the incontinence product and then held onto Resident R5 for RN-JJ.

At 7:19 a.m., RN-JJ placed a barrier on Resident R5's bed and placed the treatment supplies on the barrier. RN-JJ placed Santyl on calcium alginate, and dated the dressing. RN-JJ went into the bathroom, removed gloves, and placed the gloves on the barrier. RN-JJ asked Resident R5 if she was ready, removed the dressing from Resident R5's left upper buttocks, removed her gloves, reached into her pocket for hand sanitizer and cleansed her hands. RN-JJ placed gloves on, cleansed the wound bed with normal saline on four by four stating it's looking good , placed the Santyl with calcium alginate on the wound bed and covered with a foam dressing. RN-JJ did not remove her gloves and perform hand hygiene after cleansing Resident R5's pressure injury. RN-JJ removed her gloves, threw the barrier away, removed her gown, washed her hands and left Resident R5's room.

At 7:25 a.m. after RN-JJ had completed Resident R5's pressure injury treatment, CNA-DD placed an incontinence product along Resident R5's right side and then positioned Resident R5 from side to side to straighten out and fasten the incontinence product. Resident R5's head of the bed was raised, CNA-DD showed Resident R5 a shirt from her closet, removed

the shirt Resident R5 was wearing, applied deodorant and placed the new shirt on. CNA-DD combed Resident R5's hair, placed

a clip in her hair, lowered the head of the bed and asked Surveyor if Surveyor could help boost Resident R5. After Surveyor explained Surveyor could not assist, CNA-DD used the pad and positioned Resident R5 up in bed. CNA-DD placed pillows under Resident R5's left & right side, under Resident R5's lower legs and raised the head of the bed. CNA-DD covered Resident R5 with a sheet, placed a towel, call pad, remote & purse on Resident R5's bed. CNA-DD removed her gloves & gown and then cleansed her hands. Surveyor noted this is the first time CNA-DD performed hand hygiene

during this observation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page100of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 7/18/24, at 9:34 a.m., Surveyor asked RN/UM (Registered Nurse/Unit Manager)-AA when CNAs are doing incontinence cares when should hand hygiene be performed. RN/UM-AA informed Surveyor when Level of Harm - Minimal harm or switching from dirty to clean explaining when doing bowel care after cleaning should remove their gloves and potential for actual harm perform hand hygiene. Surveyor informed RN/UM-AA of the observation with Resident R5 & CNA-DD. Surveyor asked RN/UM-AA when should the nurse perform hand hygiene during a treatment. RN/UM-AA informed Surveyor Residents Affected - Many when the nurse enters the room, after taking the dressing off, after cleansing the wound and at the end of the treatment. Surveyor informed RN/UM-AA of the hand hygiene concerns during Resident R5 pressure injury treatment with RN-JJ.

At 9:48 a.m. Surveyor asked RN/UM-AA if a resident is on enhanced barrier precaution should staff have a gown on when repositioning. RN/UM_AA replied yes anytime they are going to come in contact with surface, gown and gloves. RN/UM-AA informed Surveyor she tells staff if they are chatting with a resident it's fine otherwise gown and gloves. Surveyor informed RN/UM-AA of the observation of CNA-KK and CNA-LL not wearing the appropriate PPE with Resident R5.

On 7/18/24, at 10:24 a.m., Surveyor informed DON (Director of Nursing)-B of the observation of staff not wearing appropriate PPE when repositioning Resident R5 and hand hygiene concerns.

On 7/18/24 at 4:06 p.m. during the end of the day meeting NHA (Nursing Home Administrator)-A was informed of the above. No additional information was provided.

38829

Unhygienic handling of urinary catheter bag

5.) Resident R25 was admitted to the facility on [DATE REDACTED] with diagnoses of Rhabdomyolysis, Type 1 Diabetes Mellitus, Alcoholic Cirrhosis of Liver with Ascites. Legal Blindness, Acquired Absence of Right Leg Below Knee, Kidney Transplant, Pancreas Transplant, and Depression.

Resident R25's Admission MDS completed on 2/23/24 documents Resident R25 has a Brief Interview for Mental Status(BIMS) score of 11, indicating Resident R25 demonstrates moderately impaired skills for daily decision making. Resident R25's MDS also documents that Resident R25 has an indwelling catheter, is on a mechanically altered diet with a feeding tube, has range of motion impairment on 1 side of lower extremity, requires partial/moderate assistance for mobility and substantial/maximum assistance for transfers.

The facility's policy Procedure: Catheter Care, Urinary dated 12/2016 and revised 1/2024 documents:

.Infection Control

2. Be sure the catheter tubing and drainage bag are kept off the floor.

On 7/15/24, at 9:55 AM, Surveyor observed Resident R25's foley catheter bag hanging on the right side of the bed, uncovered, and not facing the doorway.

On 7/15/24, at 12:58 PM, Surveyor observed Certified Nursing Assistant (CNA)-I wake Resident R25 up to eat lunch. CNA-I was on the right side of Resident R25's bed and Surveyor observed Resident R25's uncovered foley catheter bag on the floor and CNA-I did not acknowledge the catheter bag on the floor and did not pick up the catheter bag up off

the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page101of102 525552 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525552 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 7/15/24, at 2:07 PM, Surveyor observed Resident R25's foley catheter bag not covered, laying on the floor on the right side of Resident R25's bed. Level of Harm - Minimal harm or potential for actual harm On 7/15/24, at 2:24 PM, Surveyor observed Resident R25's foley catheter bag remains on the floor on the right side of Resident R25's bed. Residents Affected - Many

On 7/16/24, at 7:37, AM, Surveyor observed Resident R25's foley catheter bag hanging on the right side of Resident R25's bed and is not covered.

On 7/16/24, at 11:53 AM, Surveyor observed Resident R25's catheter bag remains hanging on the right side of Resident R25's bed.

On 7/17/24, at 7:11 AM, Surveyor observed Resident R25's foley catheter bag is laying on the floor on the right side of Resident R25's bed.

On 7/17/24, at 8:09 AM, Surveyor observed CNA-K go into Resident R25's room and was on the right side of Resident R25's bed. Surveyor observed Resident R25's catheter bag remains on the floor on the right side of Resident R25's bed. CNA-K did not pick Resident R25's catheter bag up off the floor.

On 7/17/24, at 10:51 AM, Surveyor observed Resident R25's foley catheter bag remains on the floor on the right side of Resident R25's bed.

On 7/17/24, at 12:25 PM, Surveyor interviewed Unit Manager (UM)-J who confirmed that foley catheter bags should not be on the floor. UM-J stated some Residents have behaviors and will take the catheter bags off

the bed. UM-J stated that Resident R25 will sometimes take the catheter bag off the bed, but not a whole lot.

On 7/17/24, at 3:51 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that Surveyor had multiple observations of Resident R25's foley catheter bag laying on the floor and Surveyor had observed CNA(s) go into Resident R25's room and not acknowledge that Resident R25's catheter bag was on the floor which is

an infection control issue. No further information was provided by the facility at this time.

On 7/18/24, at 10:06 AM, Surveyor shared the concern with Director

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page102of102 525552