Wheaton Franciscan Hc - Terrace At St Francis

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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 Resident R3.

No further information has been provided by the facility at this time in regard to why Resident R3's three grievances were not thoroughly investigated and a written resolution with corrective action was not provided to Resident R3 and Resident R3's daughter.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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. Resident R3 was first admitted to the facility on [DATE REDACTED] 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).Resident 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. Resident R3's Significant Change Minimum Data Set(MDS) completed 9/16/25 documents Resident R3's Brief Interview for Mental Status(BIMS) score to be 12, indicating Resident R3 is moderately cognitively impaired. Resident R3 is not demonstrating mood or behavior symptoms.On 10/27/25, at 10:27 AM, Surveyor interviewed Resident R3. Surveyor determined Resident R3 is currently alert and oriented times three.On 10/27/25, at 12:16 PM, Surveyor reviewed the facility grievance log. Resident 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:Resident R3 states, I was extremely late to lunch today because Certified Nursing Assistant (CNA)-F and his phone got me up. Resident 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 Resident 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 Resident 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 Resident 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 Resident 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

removed the pillow from under Resident R1's head & removed Resident R1's pressure relieving boots, and LPN-E removed a wedge from under Resident R1's left shoulder. LPN-E held onto Resident R1's urinary collection bag while CNA-J drained the urine into a graduate. LPN-E & CNA-J removed their gloves and performed hand hygiene after emptying

the collection bag. At 8:41 a.m. CNA-G entered Resident R1's room wearing PPE. Resident R1's bed was lowered and moved away from the bed for CNA-G to be on the right side of Resident R1's bed. At 8:44 a.m. LPN-E removed her PPE, cleansed her hands, and left Resident R1's room. CNA-J washed around Resident R1's suprapubic site, frontal area, tubing of catheter, and Resident R1's inner thighs. The sheet and soaker pad were rolled under Resident R1. CNA-J removed Resident R1's T-shirt and washed Resident R1's upper body. At 8:53 a.m. LPN-E returned to Resident R1's room. CNA-J and CNA-G placed

a new T shirt on Resident R1. LPN-E cleansed around Resident R1's suprapubic site and completed the pressure injury treatment to Resident R1's toes according to physician orders, removed her PPE, cleansed her hands and left Resident R1's roomCNA-J & CNA-G rolled Resident R1 onto his right side. CNA-J washed and dried Resident R1's buttocks. A incontinence product & soaker pad was placed under Resident R1, Resident R1 was positioned to the other side to straighten out the incontinence product & soaker pad and remove the soiled linen. Resident R1 was positioned on his back and the incontinence product was fastened. A pillow was placed under Resident R1's head, Resident R1's bed was lowered & move against the wall on the right side. CNA-G washed Resident R1's face while CNA-J covered Resident R1 with a blanket. CNA-J placed the pressure relieving boots back on Resident R1 and asked Resident R1 if he was okay. CNA-G removed her PPE, cleansed her hands and left Resident R1's room. CNA-J emptied the wash basin and shut off the overhead light.

CNA-J placed soiled items in a blue bag, told Resident R1 she would see him for lunch, removed her PPE, cleansed her hands, and left Resident R1's room with the soiled linen.Surveyor noted during this observation CNA-J did not perform or offer any oral care, to shave Resident R1 or brush/comb Resident R1's hair.On 10/28/25, at 10:48 a.m. Surveyor observed Resident R1 in bed on his back. Resident R1 has not been shaved, and his hair is still not been brushed or combed.

Survey asked Resident R1 if the CNA used mouthwash or toothbrush for oral cares this morning before breakfast. Resident R1 replied no.On 10/28/25, at 1:19 p.m., Surveyor asked CNA-J when she does oral care for Resident R1. CNA-J informed Surveyor probably every other day and explained Resident R1 can't open his mouth wide. CNA-J informed Surveyor she doesn't think a toothbrush would be able to go in Resident 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 Resident R1. CNA-J informed Surveyor when Resident R1's wife comes in she shaves him. Surveyor asked CNA-J about combing or brushing Resident R1's hair. CNA-J informed Surveyor Resident R1's wife brings in shampoo, thinks selsun blue. Resident R1's wife brushes his hair after she washes it. Surveyor asked CNA-J if she brushes or combs Resident 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 Resident 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 Resident R1's hair.No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 Resident 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 Resident R1's entire PICC line dressing was not changed weekly since Resident R1 was admitted on [DATE REDACTED]. No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

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 0686 Level of Harm - Minimal harm or potential for actual harm

On 10/27/25, at 3:59 PM, Surveyor again observed Resident R3 in bed. Resident R3's boots are on the floor next to Resident R3's bed. Resident R3's heels are not floated while in bed.

On 10/28/25, at 8:00 AM, Surveyor observed Resident R3 in bed. Resident R3's boots remain on the floor next to Resident R3's bed in

the same location as the day before. Resident R3's heels are not floated while in bed.

Residents Affected - Few

On 10/28/25, at 9:45 AM, CNA-F and CNA-G verified that Resident R3's heels are not floated.

On 10/28/25, at 10:05 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E in regard to Resident R3. LPN-E verified Resident R3 should be wearing heel boots while in bed. LPN-E stated that if Resident 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 Resident R3 in bed and Resident R3's heel boots are not on or floated.

Surveyor reviewed Resident 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 Resident 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 Resident 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 Resident R3 is at risk for developing pressure ulcers and other skin conditions and Surveyor has observed Resident R3 during the survey process not wearing Resident R3's bilateral heel boots and Resident R3's CNA worksheet instructs CNAs to place them on Resident R3 when Resident R3 is in bed.

No additional information as to why Resident R3 was not wearing Resident R3's bilateral heel boots when in bed during the survey process.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

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 0689 Level of Harm - Actual harm

and the bathroom door is closed. CNA-N placed candy on the over bed table in front of Resident R7. CNA-N informed Surveyor this is usual behavior for Resident R7, referring to having to go to the bathroom, and CNA-N had checked Resident R7 before. CNA-N asked Resident 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.

Residents Affected - Few At 12:56 p.m. CNA-N returned with a cup of coffee for Resident R7. After giving Resident R7 coffee, CNA-N opened the bathroom door. Surveyor observed Resident R6 sitting on the toilet, the New Testament book is on the handrail and Resident 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 Resident R6. CNA-N attempted to stand Resident R6 asking Resident R6 are you going to help me? Resident R6 replied I don't know. CNA-N then left Resident R6's bathroom.

At 1:00 p.m. CNA-N and CNA-K entered Resident R6's bathroom, placed gloves on, and an incontinence product was placed on Resident R6. CNA-K informed Resident R6 they were going to stand her up to clean her bottom, Resident R6 was stood up, CNA-N wiped Resident R6's with a disposable wipe and Resident R6's product and brief were pulled up. Resident R6 was then seated in the wheelchair. CNA-K removed her gloves & left Resident R6's bathroom. CNA-N stated to Resident R6 I don't want you to do any more self-transfers. Do not put yourself on toilet. CNA-N handed Resident R6 the New Testament and wheeled Resident R6 out of the bathroom into her room. CNA-N showed Resident R6 the call light and told Resident R6 to use it.

CNA-N placed the gait belt in the bathroom, gathered garbage removed her gloves & cleansed her hands.

CNA-N told Resident R6 next time to let her know when she has to go to the bathroom, don't go herself and left Resident R6's room with the garbage.

Surveyor noted Resident R6 was not toileted after lunch according to her fall plan of care and Resident R6 transferred herself.

On [DATE REDACTED], at 1:08 p.m., the facility's chaplain wheeled Resident R6 out of the room informing Surveyor she's going to take Resident R6 to services.

On [DATE REDACTED], at 10:12 a.m., Surveyor asked Licensed Practical Nurse/Interim Unit Manager (LPN/IUM)-L if Resident 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 Resident R6 not being taken to the toilet after lunch and Resident R6 self-transferred herself onto the toilet.

No additional information was provided.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

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 0690

Resident R1's spigot not being cleaned with an alcohol pad.No additional information was provided.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

wipe Resident R3's face. CNA-F did not perform hand hygiene or place gloves on. Both CNA-F and CNA-G exited Resident 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 Resident 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 Resident 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 Resident 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.

Event ID:

Facility ID:

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