Nursing homes › Wisconsin › Wheaton Franciscan HC - Terrace at St Francis
3200 S 20Th St, Milwaukee, WI 53215 · 4143893200 · 81 certified beds
Per CMS filings, this facility is affiliated with Ascension Living, a group operating 16 facilities in 8 states. Group record: average rating 2.9/5, 2 abuse citation icons, 0 facilities on the Special Focus list, $1,060,744 in federal fines. This facility rates below its group average (2.9/5).
Total nurse staffing: 3.71 (Wisconsin median: 4.06). RN hours: 0.70. Weekend total: 3.38. Nursing staff turnover: 82%.
All-time on record: 80 deficiency citations, including 1 at immediate-jeopardy level. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-01-06 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | complaint | corrected 2026-02-04 |
| 2026-01-06 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | corrected 2026-02-04 |
| 2026-01-06 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | complaint | corrected 2026-03-04 |
| 2025-10-29 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | complaint | corrected 2025-11-20 |
| 2025-10-29 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D | complaint | corrected 2025-11-20 |
| 2025-10-29 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | complaint | corrected 2025-11-20 |
| 2025-10-29 | Respond appropriately to all alleged violations. | D | complaint | corrected 2025-11-20 |
| 2025-10-29 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | complaint | corrected 2025-11-20 |
| 2025-10-29 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | corrected 2025-11-20 |
| 2025-10-29 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | complaint | corrected 2025-11-20 |
| 2025-10-29 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | complaint | corrected 2025-11-20 |
| 2025-10-29 | Provide and implement an infection prevention and control program. | D | complaint | corrected 2025-11-20 |
| 2025-08-20 | Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | F | Health | corrected 2025-09-17 |
| 2025-08-20 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | F | complaint | corrected 2025-09-17 |
| 2025-08-20 | Ensure that residents are fully informed and understand their health status, care and treatments. | E | Health | corrected 2025-09-17 |
| 2025-08-20 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | E | Health | corrected 2025-09-17 |
| 2025-08-20 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | Health | corrected 2025-09-17 |
| 2025-08-20 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E | Health | corrected 2025-09-17 |
| 2025-08-20 | Keep residents' personal and medical records private and confidential. | D | Health | corrected 2025-09-17 |
| 2025-08-20 | Respond appropriately to all alleged violations. | D | complaint | corrected 2025-09-17 |
| 2025-08-20 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Health | corrected 2025-09-17 |
| 2025-08-20 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Health | corrected 2025-09-17 |
| 2025-08-20 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | complaint | corrected 2025-09-17 |
| 2025-08-20 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Health | corrected 2025-09-17 |
| 2025-08-20 | Ensure medication error rates are not 5 percent or greater. | D | complaint | corrected 2025-09-17 |
| 2025-08-20 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | C | Health | corrected 2025-09-17 |
| 2025-06-11 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | complaint | corrected 2025-07-10 |
| 2025-06-11 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | complaint | corrected 2025-07-10 |
| 2025-04-01 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | complaint | corrected 2025-05-06 |
| 2025-04-01 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | G | complaint | corrected 2025-05-06 |
| 2025-04-01 | Provide and implement an infection prevention and control program. | F | complaint | corrected 2025-05-06 |
| 2025-04-01 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | complaint | corrected 2025-05-06 |
| 2025-04-01 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E | complaint | corrected 2025-05-06 |
| 2025-04-01 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | complaint | corrected 2025-05-06 |
| 2025-04-01 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | complaint | corrected 2025-05-06 |
| 2025-04-01 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | complaint | corrected 2025-05-06 |
| 2025-04-01 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | complaint | corrected 2025-05-06 |
| 2025-04-01 | Ensure that residents are free from significant medication errors. | D | complaint | corrected 2025-05-06 |
| 2025-04-01 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | D | complaint | corrected 2025-05-06 |
| 2024-12-18 | Ensure medication error rates are not 5 percent or greater. | D | complaint | corrected 2025-01-16 |
| Date | Type | Amount |
|---|---|---|
| 2026-01-06 | Fine | $42,680 |
| 2025-04-01 | Fine | $72,873 |
| 2025-04-01 | Payment Denial | 4 days payment denial |
| 2024-07-22 | Fine | $71,858 |
| 2024-07-22 | Payment Denial | 31 days payment denial |
| 2024-01-17 | Fine | $32,240 |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| ASCENSION HEALTH SENIOR CARE | 5% Or Greater Direct Ownership Interest | Organization | 100% | since 07/01/2014 |
| MUSGRAVE, LISA | Corporate Director | Individual | NOT APPLICABLE | since 01/01/2024 |
| SHADBOLT, ERIN | Corporate Director | Individual | NOT APPLICABLE | since 01/01/2024 |
| SMOOT, KENNETH | Corporate Director | Individual | NOT APPLICABLE | since 01/01/2024 |
| MARTHIENS, EDGAR | Operational/Managerial Control | Individual | NOT APPLICABLE | since 05/16/2022 |
| SIDHU, SARFRAZ | Operational/Managerial Control | Individual | NOT APPLICABLE | since 05/01/2025 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 525552. Corrections: data@carerecords.org.