Nursing Care Index

Wheaton Franciscan Hc - Terrace At St Francis

Milwaukee, Milwaukee County, Wisconsin · CCN 525552 · Non-profit (Corporation) · part of Ascension Living (12 facilities, chain average 2.8 stars)

CMS rates Wheaton Franciscan Hc - Terrace At St Francis 1 of 5 overall as of August 2026. 81 certified beds, 40 residents a day on average. 80 citations on record from the current inspection cycles, 1 at immediate jeopardy; 4 fines totalling $219,651 and 2 payment denials.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★☆☆☆☆ 1 of 5
Health inspections★☆☆☆☆ 1 of 5
Staffing★★☆☆☆ 2 of 5
Quality measures★★★★☆ 4 of 5
Quality: long-stay / short-stay4 / 3 of 5

Staffing

Total nurse staffing3.71012 hours per resident per day
Registered nurses0.70227 hours per resident per day
Weekend total3.37668 hours per resident per day
Nursing staff turnover81.6% (registered nurses 84.2%)

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-01-06
complaint survey
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-02-04
2026-01-06
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-02-04
2026-01-06
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-04
2025-10-29
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-11-20
2025-10-29
complaint survey
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.
Resident Rights Deficiencies · tag F0585
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-20
2025-10-29
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-20
2025-10-29
complaint survey
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-20
2025-10-29
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-20
2025-10-29
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-20
2025-10-29
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-20
2025-10-29
complaint survey
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-20
2025-10-29
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
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.
Nursing and Physician Services Deficiencies · tag F0729
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-09-17
2025-08-20
complaint survey
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-09-17
2025-08-20 Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies · tag F0552
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-09-17
2025-08-20 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies · tag F0628
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-09-17
2025-08-20 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
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.
Pharmacy Service Deficiencies · tag F0756
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-09-17
2025-08-20 Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies · tag F0583
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-17
2025-08-20
complaint survey
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-17
2025-08-20 PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · tag F0645
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-17
2025-08-20 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-17
2025-08-20
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-17
2025-08-20 Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0698
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-17
2025-08-20
complaint survey
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
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.
Nursing and Physician Services Deficiencies · tag F0725
C No actual harm, with potential for minimal harm; widespread Deficient, Provider has date of correction
2025-09-17
2025-06-11
complaint survey
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-10
2025-06-11
complaint survey
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · tag F0657
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-10
2025-04-01
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-05-06
2025-04-01
complaint survey
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-05-06
2025-04-01
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-05-06
2025-04-01
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-05-06
2025-04-01
complaint survey
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.
Pharmacy Service Deficiencies · tag F0761
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-05-06
2025-04-01
complaint survey
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-06
2025-04-01
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-06
2025-04-01
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-06
2025-04-01
complaint survey
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-06
2025-04-01
complaint survey
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-06
2025-04-01
complaint survey
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Administration Deficiencies · tag F0773
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-06
2024-12-18
complaint survey
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-16
2024-08-28
complaint survey
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-09-20
2024-08-28
complaint survey
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-09-20
2024-07-22
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-08-19
2024-07-22 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-08-19
2024-07-22
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-08-19
2024-07-22 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2024-08-19
2024-07-22 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2024-08-19
2024-07-22 Assure that each resident’s assessment is updated at least once every 3 months.
Resident Assessment and Care Planning Deficiencies · tag F0638
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-08-19
2024-07-22 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · tag F0756
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-08-19
2024-07-22
complaint survey
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Resident Rights Deficiencies · tag F0553
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-19
2024-07-22 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-19
2024-07-22
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-19
2024-07-22
complaint survey
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-19
2024-07-22 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Resident Assessment and Care Planning Deficiencies · tag F0636
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-19
2024-07-22 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-19
2024-07-22 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-19
2024-07-22 Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-09-20
2024-07-22 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Pharmacy Service Deficiencies · tag F0758
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-19
2024-07-22 Provide or obtain dental services for each resident.
Quality of Life and Care Deficiencies · tag F0791
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-19
2024-07-22 Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Nutrition and Dietary Deficiencies · tag F0810
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-19
2024-07-22 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Administration Deficiencies · tag F0849
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-19
2024-02-28
complaint survey
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-03-04
2024-01-17
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
J Immediate jeopardy to resident health or safety; isolated Deficient, Provider has date of correction
2024-02-16
2024-01-17
complaint survey
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-02-16
2024-01-17
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-02-16
2024-01-17
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-02-16
2024-01-17
complaint survey
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-02-16
2024-01-17
complaint survey
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-16
2024-01-17
complaint survey
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Quality of Life and Care Deficiencies · tag F0693
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-16
2024-01-17
complaint survey
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Nursing and Physician Services Deficiencies · tag F0947
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-16
2023-10-05
complaint survey
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-05
2023-10-05
complaint survey
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-05
2023-10-05
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-05
2023-04-01 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-05-18
2023-04-01 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Resident Assessment and Care Planning Deficiencies · tag F0636
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-05-18
2023-04-01 Assess the resident when there is a significant change in condition
Resident Assessment and Care Planning Deficiencies · tag F0637
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-05-18
2023-04-01 Assure that each resident’s assessment is updated at least once every 3 months.
Resident Assessment and Care Planning Deficiencies · tag F0638
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-05-18
2023-04-01 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-05-18
2023-04-01 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-05-18
2023-04-01 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-05-18

Fines and payment denials

DatePenaltyAmount
2026-01-06Fine$42,680
2025-04-01Payment denial for 4 days from 2025-05-02
2025-04-01Fine$72,873
2024-07-22Payment denial for 31 days from 2024-08-20
2024-07-22Fine$71,858
2024-01-17Fine$32,240

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Ascension Health Senior Care
Organization
5% or greater direct ownership interest100%2014-07-01
Ascension Health Senior Care
Organization
adp of the snf2015-07-01
House Healthcare Solutions LLC
Organization
adp of the snf2025-06-10
Medical Solutions LLC
Organization
adp of the snf2017-06-14
Metis Ltc LLC
Organization
adp of the snf2024-04-08
Michael Porter
Organization
adp of the snf2021-05-09
Nursing Centers, Inc.
Organization
adp of the snf2025-06-03
Marthiens, Edgar
Individual
adp of the snf2022-05-16
Musgrave, Lisa
Individual
adp of the snf2024-01-01
Shadbolt, Erin
Individual
adp of the snf2024-01-01
Sidhu, Sarfraz
Individual
adp of the snf2025-05-01
Smoot, Kenneth
Individual
adp of the snf2024-01-01
Musgrave, Lisa
Individual
corporate director2024-01-01
Shadbolt, Erin
Individual
corporate director2024-01-01
Smoot, Kenneth
Individual
corporate director2024-01-01
Marthiens, Edgar
Individual
operational/managerial control2022-05-16
Sidhu, Sarfraz
Individual
operational/managerial control2025-05-01

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Milwaukee County.