Wheaton Franciscan Hc - Terrace At St Francis
Wheaton Franciscan HC - Terrace at St Francis in MILWAUKEE, WI — inspection on October 29, 2025.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
grievances was not completed, corrective action taken was not taken, and required written
No further information has been provided by the facility at this time in regard to why R3's three grievances were not thoroughly investigated and a written resolution with corrective action was not provided to R3 and R3's daughter.
525552 10/29/2025
Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215
diagnoses of Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the
enough healthy red blood cells to carry oxygen throughout body, Hypothyroidism(underactive thyroid),
pleasure in activities), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life).R3 was discharged to the hospital on 8/18/25 and returned from the hospital on 9/11/25 with a diagnosis of Non-displaced Oblique Fracture of the Distal Shaft of Left Femur. R3's Significant Change Minimum Data Set(MDS) completed 9/16/25 documents R3's Brief Interview for Mental Status(BIMS) score to be 12, indicating R3 is moderately cognitively impaired. R3 is not demonstrating mood or behavior symptoms.On 10/27/25, at 10:27 AM, Surveyor interviewed R3.
Surveyor determined R3 is currently alert and oriented times three.On 10/27/25, at 12:16 PM, Surveyor reviewed the facility grievance log. R3 has two listed grievances for 8/8/25, and 9/8/25.
Surveyor requested and received the written grievances for those dates from the facility.8/8/25-The grievance documents:R3 states, I was extremely late to lunch today because Certified Nursing Assistant (CNA)-F and his phone got me up. R3 stated cares were put on pause so CNA-F could discuss care issues on the phone.Surveyor reviewed the grievance dated 8/27/25 which documents:-Showers have not been completed, with CNA-F documenting multiple refusals while other staff are able to accomplish the task.-One resident reported needing assistance in cleaning up food that had spilled from her bedside table; she stated that CNA-F refused to help her with the cleanup.-Another resident expressed wanting to get up and be ready for therapy, but CNA-F reportedly came, turned off light and left the room, leaving her unattended.-3rd resident reported she was extremely late to lunch because CNA-F on CNA-F's phone instead of getting R3 cleaned up to go to breakfast.On 10/28/25, at 11:01 AM, Surveyor interviewed Social Worker (SW)-I. SW-I stated SW-I is not involved in the grievance process other than to just enter grievances on a grievance spreadsheet.
SW-I is not involved in the investigation process of any allegations of neglect or abuse.On 10/28/25, at 11:10 AM, Surveyor spoke with Nursing Home Administrator (NHA)-A. NHA-A confirmed there is no formal grievance process currently in the facility.
Surveyor shared with NHA-A the concern that there are multiple residents including R3 that shared concerns of neglect that were not reported to the State Survey Agency and were not thoroughly investigated by the facility. NHA-A informed Surveyor that NHA-A would look for additional information in regard to the allegations of neglect. NHA-A understands the concern that residents' allegations of neglect were not reported to the State Survey Agency.On 10/28/25, at 3:01 PM, Surveyor shared the concern to NHA-A and Director of Nursing (DON-B) that R3's and other residents' allegations of neglect were not reported to the State Survey Agency.No additional information was provided as to why the facility did not report the allegations of neglect to the State Survey Agency.
525552 10/29/2025
Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215
other officials or agencies:1.The State licensing/certification agency responsible for
reported:1.Abuse or Serious Bodily Harm-Immediately but not later than 2 hours. If the alleged
practical, but not later than 24 hours. If the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property; does not result in serious bodily injury.E.
The administrator or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five(5) working days of the occurrence of the incident. R3 was first admitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart) Block, Paroxysmal Atrial Fibrillation(irregular heartbeats occur intermittently and spontaneously resolve within 7 days), Iron Deficiency Anemia(blood does not have enough healthy red blood cells to carry oxygen throughout body, Hypothyroidism(underactive thyroid), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life).R3 was discharged to the hospital on 8/18/25 and returned from the hospital on 9/11/25 with a diagnosis of Non-displaced Oblique Fracture of the Distal Shaft of Left Femur. R3's Significant Change Minimum Data Set(MDS) completed 9/16/25 documents R3's Brief Interview for Mental Status(BIMS) score to be 12, indicating R3 is moderately cognitively impaired. R3 is not demonstrating mood or behavior symptoms.On 10/27/25, at 10:27 AM, Surveyor interviewed R3.
Surveyor determined R3 is currently alert and oriented times three.On 10/27/25, at 12:16 PM, Surveyor reviewed the facility grievance log. R3 has two listed grievances for 8/8/25, and 9/8/25.
Surveyor requested and received the written grievances for those dates from the facility.The grievance dated 8/8/25 documents:R3 states, I was extremely late to lunch today because Certified Nursing Assistant (CNA)-F and his phone got me up. R3 stated cares were put on pause so CNA-F could discuss care issues on the phone.Surveyor reviewed the grievance which documents that Certified Nursing Assistant (CNA)-F received a documented counseling session dated 8/27/25.The area of concern documents:-Showers have not been completed, with CNA-F documenting multiple refusals while other staff are able to accomplish the task.-One resident reported needing assistance in cleaning up food that had spilled from her bedside table; she stated that CNA-F refused to help her with the cleanup.-Another resident expressed wanting to get up and be ready for therapy, but CNA-F reportedly came, turned off light and left the room, leaving her unattended.-3rd resident reported she was extremely late to lunch because CNA-F on CNA-F's phone instead of getting R3 cleaned up to go to breakfast.On 10/28/25, at 11:01 AM, Surveyor interviewed Social Worker (SW)-I. SW-I stated SW-I is not involved in the grievance process other than to just enter grievances on a grievance spreadsheet. SW-I is not involved in the investigation process of any allegations of neglect or abuse.On 10/28/25, at 11:10 AM, Surveyor spoke with Nursing Home Administrator (NHA)-A. NHA-A confirmed there is no formal grievance process currently in the facility.
Surveyor shared with NHA-A the concern that there are multiple residents including R3 that shared concerns of neglect that were not reported to the State Survey Agency and were not thoroughly investigated by the facility. NHA-A informed Surveyor that NHA-A would look for additional information in regard to the allegations of neglect. NHA-A understands the concern that residents' allegations of neglect were not thoroughly investigated and reported to the State Survey Agency.On 10/28/25, at 3:01 PM, Surveyor shared the concern to NHA-A and Director of Nursing (DON-B) that R3's and other residents' allegations of neglect were not thoroughly investigated, and the investigation findings was not submitted to the State Survey Agency.No additional information was provided as to why the facility did not thoroughly investigate and submit the findings of the allegations of neglect to the State Survey Agency.
525552 10/29/2025
Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215
Survey asked R1 if the CNA used mouthwash or toothbrush for oral cares this morning before breakfast. R1 replied no.On 10/28/25, at 1:19 p.m., Surveyor asked CNA-J when she does oral care for R1. CNA-J informed Surveyor probably every other day and explained R1 can't open his mouth wide. CNA-J informed Surveyor she doesn't think a toothbrush would be able to go in R1's mouth.
Surveyor asked CNA-J if the facility has toothette oral swabs if she can't use a toothbrush.
CNA-J informed Surveyor she doesn't know if they have these.
Surveyor asked if she shaves R1.
CNA-J informed Surveyor when R1's wife comes in she shaves him.
Surveyor asked CNA-J about combing or brushing R1's hair. CNA-J informed Surveyor R1's wife brings in shampoo, thinks selsun blue. R1's wife brushes his hair after she washes it.
Surveyor asked CNA-J if she brushes or combs R1's hair. CNA-J replied no.On 10/28/25, at 2:14 p.m., Surveyor asked Registered Nurse/Interim Unit Manager (RN/IUM)-M if staff shave residents. RN/IUM-M replied yes.
Surveyor asked if they brush or comb residents' hair. RN/IUM-M replied yes.
Surveyor asked if staff does oral care. RN/IUM-M replied yes.
Surveyor informed RN/IUM-M R1 is dependent on staff for his ADL's and during morning care observations CNA-J did not offer or do oral care, shave or brush/comb R1's hair.No additional information was provided.
525552 10/29/2025
Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215
incorrectly entered. DON-B informed Surveyor she thinks the person putting in the order was trying to
admitted on [DATE]. No additional information was provided.
525552 10/29/2025
Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215
R3's heels are not floated while in bed.
bed. R3's heels are not floated while in bed.
On 10/28/25, at 8:00 AM, Surveyor observed R3 in bed. R3's boots remain on the floor next to R3's bed in the same location as the day before. R3's heels are not floated while in bed.
On 10/28/25, at 9:45 AM, CNA-F and CNA-G verified that R3's heels are not floated.
On 10/28/25, at 10:05 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E in regard to R3.
LPN-E verified R3 should be wearing heel boots while in bed. LPN-E stated that if R3 is refusing to wear the heel boots, the CNAs should be informing the nurse so the nurse can document the refusal.
On 10/29/25, at 7:25 AM, Surveyor observed R3 in bed and R3's heel boots are not on or floated.
Surveyor reviewed R3's Treatment Administration Record(TAR) for October.
Offload both heels while resident is in bed, every shift with a start date of 9/15/25.
Surveyor notes that nursing staff have been documenting R3's heels boots have been on 10/27, 10/28, and 10/29/25 on all 3 shifts even though Surveyor has had observations of R3's heels not floated and no heel boots are on.
On 10/28/25, at 3:01 PM, Surveyor with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R3 is at risk for developing pressure ulcers and other skin conditions and Surveyor has observed R3 during the survey process not wearing R3's bilateral heel boots and R3's CNA worksheet instructs CNAs to place them on R3 when R3 is in bed.
No additional information as to why R3 was not wearing R3's bilateral heel boots when in bed during the survey process.
525552 10/29/2025
Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215
and left the bathroom. CNA-N returned with a gait belt and placed the gait belt around R6. CNA-N
R6's bathroom.
At 1:00 p.m. CNA-N and CNA-K entered R6's bathroom, placed gloves on, and an incontinence product was placed on R6. CNA-K informed R6 they were going to stand her up to clean her bottom, R6 was stood up, CNA-N wiped R6's with a disposable wipe and R6's product and brief were pulled up. R6 was then seated in the wheelchair. CNA-K removed her gloves & left R6's bathroom. CNA-N stated to R6 I don't want you to do any more self-transfers. Do not put yourself on toilet. CNA-N handed R6 the New Testament and wheeled R6 out of the bathroom into her room. CNA-N showed R6 the call light and told R6 to use it. CNA-N placed the gait belt in the bathroom, gathered garbage removed her gloves & cleansed her hands. CNA-N told R6 next time to let her know when she has to go to the bathroom, don't go herself and left R6's room with the garbage.
Surveyor noted R6 was not toileted after lunch according to her fall plan of care and R6 transferred herself.
On [DATE], at 1:08 p.m., the facility's chaplain wheeled R6 out of the room informing Surveyor she's going to take R6 to services.
On [DATE], at 10:12 a.m., Surveyor asked Licensed Practical Nurse/Interim Unit Manager (LPN/IUM)-L if R6 has a fall intervention to take resident to toilet after meals what is the expectation. LPN/IUM-L stated right after meal.
Surveyor asked LPN/IUM-L how would the CNA know this. LPN/IUM-L informed Surveyor the care card is updated with the fall intervention plan.
Surveyor informed LPN/IUM-L of the observation of R6 not being taken to the toilet after lunch and R6 self-transferred herself onto the toilet.
No additional information was provided.
525552 10/29/2025
Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215
During this observation Surveyor did not observe a stat lock to hold R1's catheter tubing.On 10/28/25, at 10:33 a.m., Surveyor asked LPN-E if R1 should have a stat lock on for the catheter tubing. LPN-E replied yes.
Surveyor informed LPN-E R1 does not have a stat lock on. LPN-E stated Oh my God I didn't even notice it. I'll put one on.On 10/28/25, at 11:00 a.m.
Surveyor asked Director of Nursing (DON)-B procedure for emptying a urinary catheter bag. DON-B informed Surveyor staff should place gloves on, remove spigot, empty, clean tip and place back in holder, empty in commode, and rinse.
Surveyor informed DON-B of the observation of R1's spigot not being cleaned with an alcohol pad.No additional information was provided.
525552 10/29/2025
Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215
10/28/25, at 3:01 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing
additional information has been provided by the facility as to why CNA-F and CNA-G did not perform
Surveyor interviewed Registered Nurse (RN)-H who confirmed that RN-I is the facility Infection Preventionist. RN-H stated that staff were trained about two months ago on hand hygiene. RN-H stated the expectation is that staff perform hand hygiene prior to entering a resident room, perform resident activities, and perform hand hygiene prior to leaving the resident room.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.