01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-08-20 | 26 | 2025-08-20 | 6 |
| Cycle 2 | 2024-07-22 | 35 | 2024-07-22 | 11 |
| Cycle 3 | 2023-04-01 | 19 | 2023-04-01 | 6 |
CMS CCN 5255522026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Wheaton Franciscan Hc - Terrace At St Francis
3200 S 20Th St · Milwaukee, WI 53215 · Milwaukee County
Certified beds81CMS provider file
Recent citation rows103current CMS citation release
Penalty rows6current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
103 rows in the current release
11 rows carry G–L scope/severity codes; 1 carry J–L. 20 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-01-06 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2026-02-04 · complaint2026-01-06 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-02-04 · complaint2026-01-06 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-03-04 · complaint2025-10-29 · HEALTHF0585Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-11-20 · complaint2025-10-29 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-11-20 · complaint2025-10-29 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2025-11-20 · complaint2025-10-29 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-11-20 · complaint2025-10-29 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-11-20 · complaint2025-10-29 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-11-20 · complaint2025-10-29 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-11-20 · complaint2025-10-29 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2025-11-20 · complaint2025-10-29 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-11-20 · complaint2025-08-20 · FIREE0030Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
List the names and contact information of those in the facility.
Correction field: Deficient, Provider has date of correction · 2025-09-172025-08-20 · HEALTHF0552Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2025-09-172025-08-20 · HEALTHF0583Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2025-09-172025-08-20 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2025-09-17 · complaint2025-08-20 · HEALTHF0628Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2025-09-172025-08-20 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2025-09-172025-08-20 · HEALTHF0684Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-09-172025-08-20 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-09-172025-08-20 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-09-17 · complaint2025-08-20 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-09-172025-08-20 · HEALTHF0725Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Correction field: Deficient, Provider has date of correction · 2025-09-172025-08-20 · HEALTHF0729Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Correction field: Deficient, Provider has date of correction · 2025-09-1703 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2026-01-06 | Fine | $42,680 | 0 |
| 2025-04-01 | Fine | $72,873 | 0 |
| 2025-04-01 | Payment Denial | $0 | 4 |
| 2024-07-22 | Fine | $71,858 | 0 |
| 2024-07-22 | Payment Denial | $0 | 31 |
| 2024-01-17 | Fine | $32,240 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- ASCENSION HEALTH SENIOR CAREOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 07/01/2014
- MUSGRAVE, LISAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- SHADBOLT, ERINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- SMOOT, KENNETHIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- MARTHIENS, EDGARIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/16/2022
- SIDHU, SARFRAZIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2025
- ASCENSION HEALTH SENIOR CAREOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/01/2015
- HOUSE HEALTHCARE SOLUTIONS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 06/10/2025
- MEDICAL SOLUTIONS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 06/14/2017
- METIS LTC LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/08/2024
- MICHAEL PORTEROrganization · ADP OF THE SNFNOT APPLICABLE · since 05/09/2021
- NURSING CENTERS, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 06/03/2025
- MARTHIENS, EDGARIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/16/2022
- MUSGRAVE, LISAIndividual · ADP OF THE SNFNOT APPLICABLE · since 01/01/2024
- SHADBOLT, ERINIndividual · ADP OF THE SNFNOT APPLICABLE · since 01/01/2024
- SIDHU, SARFRAZIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/01/2025
- SMOOT, KENNETHIndividual · ADP OF THE SNFNOT APPLICABLE · since 01/01/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.71per resident day
RN hours0.70per resident day
Weekend nurse hours3.38per resident day
Staff turnover81.6%CMS reported field
06 / LOCAL RECORDS
Open the Milwaukee ledger →Other published facilities nearby
Amethyst Health Of Brown Deer87 beds · CMS overall 1/5116 citation rowsAutumn Lake Healthcare At Greenfield112 beds · CMS overall 1/595 citation rowsAvina Of Milwaukee108 beds · CMS overall 1/5119 citation rowsBradley Estates Nursing And Rehab Llc198 beds · CMS overall 1/5189 citation rowsEastcastle Pl Bradford Ter Conv Ctr40 beds · CMS overall 5/522 citation rowsEdenbrook Lakeside145 beds · CMS overall 1/564 citation rowsJewish Home And Care Center102 beds · CMS overall 1/549 citation rowsLuther Manor99 beds · CMS overall 1/583 citation rows