Chi Franciscan Villa
Chi Franciscan Villa in SOUTH MILWAUKEE, WI — inspection on December 23, 2025.
Found 1 citation. 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
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure a resident representative written request for a medical record was granted.
This was observed with 1 (R3) of 1 resident record requests reviewed. * R3's Representative requested, in writing, a copy of R3's medical record.
When initially requested, R3 was responsible for themself and decisions and R3's Representative was not eligible to receive the records. In the day's following the request and denial, R3's Power of Attorney for Health Care (POAHC) status was reviewed and activated naming R3's Represebtative as the POAHC.
The facility did not address the request for records given the change in R3's POAHC status.
Findings include:The facility policy and procedure (Name of facility) administrative standards for medical record release dated 5/22/2025.
Under 4.) Information from a medical record is released to individuals only upon receipt of a properly executed authorization from the resident for their legal representative.Findings include:R3 was readmitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Altered Mental Status and Pressure Ulcer Sacral Stage 4. R3's medical record contained a document authorization for use or disclosure of protected health information access to protected health information.
This was signed by R3's family member on 12/3/2025.
The document did not contain authorization by R3, who was their own decision maker until 12/10/2025. On 12/10/2025 R3's Power of Attorney for Healthcare was activated.
The Agent listed is the same family member that requested R3's medical records. On 12/22/25, at 10:57 AM, Surveyor interviewed R3's Power of Attorney for Healthcare Agent regarding the medical record request.
The Family member stated they have not received any medical records, and the form was not valid.On 12/22/25, at 12:45 PM, Surveyor interviewed the Nursing Home Administrator (NHA) - A who signed R3's medical record release form on 12/3/2025.
The NHA-A stated on 12/3/25 they did not realize R3's Power of Attorney for Healthcare was not activated.
The facility legal representatives stated they could not release the medical records due to R3 being their own person on 12/3/25. R3 did not sign the medical record release form due to being in the hospital. R3 had a hospital stay from 12/2/25 - 12/11/25.
The request by R3's family member for medical records was not acted upon by the facility.
The NHA-A stated they did not follow-up with the medical record request from 12/3/25 that was denied.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
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