Chi Franciscan Villa
Inspection Findings
F-Tag F0580
F 0580
include. Significant change in the resident's physical, mental, or psychosocial condition, such as deterioration in health. This may include. Clinical complications.
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
10/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Chi Franciscan Villa
3601 S Chicago Ave South Milwaukee, WI 53172
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-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to maintain a complete and accurate medical record for one (Resident (R)1) of five sample residents. Findings include:Review of Resident R1's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated Resident R1 was admitted to the facility on [DATE REDACTED] and readmitted to the facility on [DATE REDACTED] with the diagnoses of acute respiratory failure with hypoxia, anoxic brain damage, and congestive heart failure.
Review of Resident 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 Resident R1 was coded to be in a persistent vegetative state with no discernable consciousness. The MDS indicated that Resident R1 was coded as having a tracheostomy.
Review of Resident 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:
- 1. Assess for suctioning every two hours and as needed. Documentation indicated this task was not
- 2. Cleanse trach site with normal saline and hydrogen peroxide, pat dry and apply fresh gauze dressing
- 3. Change/clean inner cannula #6 [NAME] flex every 12 hours. 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.
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.
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 Resident 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.
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
10/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Chi Franciscan Villa
3601 S Chicago Ave South Milwaukee, WI 53172
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-Tag F0880
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.
CHI FRANCISCAN VILLA in SOUTH MILWAUKEE, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SOUTH MILWAUKEE, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CHI FRANCISCAN VILLA or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.