Chi Franciscan Villa

Review of R1's admission Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment reference Date (ARD) of 07/28/25 indicated R1 was coded to be in a persistent vegetative state with no discernable consciousness.

The MDS indicated that R1 was coded as having a tracheostomy.

Review of R1's Treatment Administration Record (TAR) located under the Orders tab in the EMR and dated for the months of August through October 2025 indicated missing documentation to reflect the care was performed and completed for the following tasks:

• Assess for suctioning every two hours and as needed.

Documentation indicated this task was not completed as evidenced by an empty box on with no initials of the nurse on 08/01/25 at 10:00 AM and 2:00 PM, 08/03/25 at 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, and 2:00 PM, 08/05/25 at 4:00 AM and 6:00 AM, 09/01/25, 09/02/25, 09/06/25, and 09/07/25 at 8:00 AM, 10:00 AM, 12:00 PM, and 2:00 PM, 09/17/25 at 4:00 PM, 6:00 PM, 09/28/25 at 2:00 AM, 4:00 AM, and 6:00 AM, 10/04/25at 10:00 AM, 12:00 PM, and 2:00 PM, and on 10/11/25 at 10:00 AM, 12:00 PM, and 2:00 PM.

• Cleanse trach site with normal saline and hydrogen peroxide, pat dry and apply fresh gauze dressing

every shift.

Documentation indicated this task was not completed as evidenced by an empty box with no initials of the nurse on 08/09/25, 08/10/25, 09/01/25, 09/02/25, 09/06/25, 09/07/25, 09/14/25 and 09/20/25 on the day shift and 09/17/25 on the evening shift, 10/04/25, 10/11/25, and 10/14/25 on the day shift.

• Change/clean inner cannula #6 [NAME] flex every 12 hours.

Documentation indicated this task was not completed as evidenced by an empty box with no initials of the nurse on 08/03/25, 08/07/25, 08/09/25, 09/01/25, 09/02/25, 09/06/25, 09/07/25, 09/14/25, 09/20/25 on the day shift.

During an interview on 10/17/25 at 3:46 PM, Registered Nurse (RN)2 stated, If there is no documentation in the boxes for the treatments, then one is to assume that the task was not done.

You sign each task off as you do the treatments and that shows the task was completed. RN2 confirmed there was missing documentation on the TARs for the months of August through October 2025 for the above documented tasks.

During an interview on 10/17/25 at 4:15 PM, the Director of Nursing (DON) reviewed R1's TARs for August through October 2025and confirmed that there was missing documentation on the TARs for the above documented tasks.

The DON stated, The nurse is to click on each task that is performed, and this will document the nurses' initials in the boxes which represent the task that was completed as ordered. I don't know if they forgot to click on each task or if they overlooked this altogether.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Chi Franciscan Villa

3601 S Chicago Ave South Milwaukee, WI 53172

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited CHI FRANCISCAN VILLA in SOUTH MILWAUKEE, WI for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-10-17.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of CHI FRANCISCAN VILLA.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-12-05.