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
at the facility. NHA-A stated SW-I should be in charge of the grievance process but SW-I is not. NHA-A explained that SW-I is contracted.
On 10/28/25, at 3:01 PM, Surveyor shared with NHA-A and Director of Nursing (DON)-B there is a concern with the facility's grievance process.
Surveyor shared a thorough investigation of the grievances was not completed, corrective action taken was not taken, and required written notification was not implemented and completed involving R3.
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheaton Franciscan Hc - Terrace at St Francis
3200 S 20th St Milwaukee, WI 53215
SUMMARY STATEMENT OF DEFICIENCIES
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.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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheaton Franciscan Hc - Terrace at St Francis
3200 S 20th St Milwaukee, WI 53215
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheaton Franciscan Hc - Terrace at St Francis
3200 S 20th St Milwaukee, WI 53215
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheaton Franciscan Hc - Terrace at St Francis
3200 S 20th St Milwaukee, WI 53215
SUMMARY STATEMENT OF DEFICIENCIES
thinks they changed the order yesterday.
Surveyor asked RN/IUM-M if the order should have been entered to change the entire dressing weekly not just the transparent portion. RN/IUM-M stated I just got it from the library, now you brought it to our attention we fixed it.
Thank you.On 10/29/25, at 10:33 a.m., Surveyor asked DON-B if she knew why R1's PICC line dressing was incorrectly entered. DON-B informed Surveyor she thinks the person putting in the order was trying to be helpful, and the correct template wasn't chosen that's way the entire dressing wasn't changed.Surveyor noted R1's entire PICC line dressing was not changed weekly since R1 was admitted on [DATE]. No additional information was provided.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheaton Franciscan Hc - Terrace at St Francis
3200 S 20th St Milwaukee, WI 53215
SUMMARY STATEMENT OF DEFICIENCIES
On 10/27/25, at 3:59 PM, Surveyor again observed R3 in bed. R3's boots are on the floor next to R3's 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheaton Franciscan Hc - Terrace at St Francis
3200 S 20th St Milwaukee, WI 53215
SUMMARY STATEMENT OF DEFICIENCIES
and the bathroom door is closed. CNA-N placed candy on the over bed table in front of R7. CNA-N informed Surveyor this is usual behavior for R7, referring to having to go to the bathroom, and CNA-N had checked R7 before. CNA-N asked R7 if she wanted something to drink and left the room.
Surveyor noted CNA-N did not check the bathroom prior to leaving the room.
At 12:56 p.m. CNA-N returned with a cup of coffee for R7.
After giving R7 coffee, CNA-N opened the bathroom door.
Surveyor observed R6 sitting on the toilet, the New Testament book is on the handrail and R6's wheelchair is next to the toilet. CNA-N placed gloves on, stated let me get a gait belt for her and left the bathroom. CNA-N returned with a gait belt and placed the gait belt around R6. CNA-N attempted to stand R6 asking R6 are you going to help me? R6 replied I don't know. CNA-N then left 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheaton Franciscan Hc - Terrace at St Francis
3200 S 20th St Milwaukee, WI 53215
SUMMARY STATEMENT OF DEFICIENCIES
R1's spigot not being cleaned with an alcohol pad.No additional information was provided.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheaton Franciscan Hc - Terrace at St Francis
3200 S 20th St Milwaukee, WI 53215
SUMMARY STATEMENT OF DEFICIENCIES
wipe R3's face. CNA-F did not perform hand hygiene or place gloves on.
Both CNA-F and CNA-G exited R3's room and did not perform hand hygiene.
Team member Surveyor observed CNA-G take the mechanical lift and place in the equipment room.
Surveyor observed CNA-G not wipe down the mechanical lift after use in transferring R3.On 10/28/25, at 3:01 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concern that CNA-F and CNA-G did not perform hand hygiene before, during, and after transferring R3 with the mechanical lift and did not wipe down the mechanical lift after use.No additional information has been provided by the facility as to why CNA-F and CNA-G did not perform hand hygiene or wipe down the mechanical lift with the transfer of R3.On 10/29/25, at 7:37 AM, 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.
Facility ID: