Federal inspection record · CMS data as of October 1, 2026
Wheaton Franciscan HC - Terrace at St Francis
3200 S 20th St, Milwaukee, WI · (414) 389-3200
- Certified beds
- 81
- Residents per day
- 43
- Ownership
- Non-Profit
- Chain
- Ascension Living
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- September 23, 1994
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Wisconsin.
-
Staffing
★★★★★no change (already 1)
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Wisconsin homes
Wheaton Franciscan HC - Terrace at St Francis carries 230.75 inspection points. That is fewer than 10% of Wisconsin's 321 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Wisconsin: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–11 pts
- 4★ 11–37 pts
- 3★ 37–76 pts
- 2★ 76–130.75 pts
- 1★ over 130.75 pts
Bars show every rated home in Wisconsin by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
80 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (11)
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
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
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Everything else, by area of care
Quality of Life and Care21E
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe, appropriate pain management for a resident who requires such services.
- D
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
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe, appropriate pain management for a resident who requires such services.
- D
Provide or obtain dental services for each resident.
- D
Provide enough food/fluids to maintain a resident's health.
- D
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.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Pharmacy Service15F
- F
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
Ensure medication error rates are not 5 percent or greater.
- E
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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure that residents are free from significant medication errors.
- D
Ensure medication error rates are not 5 percent or greater.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure medication error rates are not 5 percent or greater.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure medication error rates are not 5 percent or greater.
Resident Rights8E
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
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.
- E
Ensure that residents are fully informed and understand their health status, care and treatments.
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Keep residents' personal and medical records private and confidential.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Freedom from Abuse, Neglect, and Exploitation7D
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
- D
Respond appropriately to all alleged violations.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Resident Assessment and Care Planning7E
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- E
Assure that each resident’s assessment is updated at least once every 3 months.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- D
Assess the resident when there is a significant change in condition
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Infection Control4F
- D
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Nursing and Physician Services3F
- F
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
- C
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Administration2D
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
- D
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.
Nutrition and Dietary2F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspection history
2025-08-20
26 health deficiencies · 6 fire-safety deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
2024-07-22
33 health deficiencies · 11 fire-safety deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
2023-04-01
21 health deficiencies · 6 fire-safety deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 6 min of nursing staff time a day, 44 min of it from a registered nurse.
This home
3 h 6 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 81% of nursing staff and 88% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$276,051 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2026-01-06 | Fine | $42,680 |
| 2025-10-29 | Fine | $56,400 |
| 2025-04-01 | Fine | $72,873 |
| 2025-04-01 | Payment Denial · 4 day denial | $0 |
| 2024-07-22 | Fine | $71,858 |
| 2024-07-22 | Payment Denial · 31 day denial | $0 |
| 2024-01-17 | Fine | $32,240 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine3.2 pts better | 99.2% | 96.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine4.4 pts better | 100.0% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.2 pts better | 3.1% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms4.1 pts better | 1.9% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.1 pts better | 4.8% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication10.2 pts better | 6.6% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication14.5 pts better | 1.4% | 15.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened5.3 pts better | 11.7% | 17.0% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased0.7 pts better | 15.1% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.9 pts better | 0.0% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.9 pts better | 0.8% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence9.8 pts better | 13.8% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers4.7 pts worse | 9.6% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine10.1 pts better | 97.0% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit11 pts better | 4.6% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.2 pts better | 0.0% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine15.2 pts better | 97.4% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission1.9 pts worse | 24.4% | 22.5% | 23.4% |
·
Who owns and runs it
17 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Ascension Health Senior Care | 5% Or Greater Direct Ownership Interest · Organization | 100% | 11 facilities |
| Ascension Health Senior Care | Adp Of The SNF · Organization | 0% | 11 facilities |
| House Healthcare Solutions LLC | Adp Of The SNF · Organization | 0% | 5 facilities |
| Marthiens, Edgar | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Marthiens, Edgar | Adp Of The SNF · Individual | 0% | 1 facilities |
| Medical Solutions LLC | Adp Of The SNF · Organization | 0% | 16 facilities |
| Metis Ltc LLC | Adp Of The SNF · Organization | 0% | 2 facilities |
| Michael Porter | Adp Of The SNF · Organization | 0% | 2 facilities |
| Musgrave, Lisa | Corporate Director · Individual | 0% | 11 facilities |
| Musgrave, Lisa | Adp Of The SNF · Individual | 0% | 11 facilities |
| Nursing Centers, Inc. | Adp Of The SNF · Organization | 0% | 2 facilities |
| Shadbolt, Erin | Corporate Director · Individual | 0% | 11 facilities |
| Shadbolt, Erin | Adp Of The SNF · Individual | 0% | 11 facilities |
| Sidhu, Sarfraz | Operational/Managerial Control · Individual | 0% | 28 facilities |
| Sidhu, Sarfraz | Adp Of The SNF · Individual | 0% | 28 facilities |
| Smoot, Kenneth | Corporate Director · Individual | 0% | 10 facilities |
| Smoot, Kenneth | Adp Of The SNF · Individual | 0% | 10 facilities |
·
Fire safety
23 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke5F
- D
Inspect, test, and maintain automatic sprinkler systems.
- F
Install a fire alarm system that can be heard throughout the facility.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- E
Provide properly protected cooking facilities.
- D
Inspect, test, and maintain automatic sprinkler systems.
Miscellaneous5F
- D
Have restrictions on the use of highly flammable decorations.
- C
Have simulated fire drills held at unexpected times.
- F
Provide a written emergency evacuation plan.
- F
Have simulated fire drills held at unexpected times.
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Gas, Vacuum, and Electrical Systems5F
- D
Ensure proper usage of power strips and extension cords.
- C
Have generator or other power source capable of supplying service within 10 seconds.
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Ensure proper usage of power strips and extension cords.
Emergency Preparedness3F
- F
List the names and contact information of those in the facility.
- F
Conduct testing and exercise requirements.
- F
Conduct risk assessment and an All-Hazards approach.
Egress2F
- F
Install emergency lighting that can last at least 1 1/2 hours.
- D
Install proper backup exit lighting.
Services2E
- E
Install properly constructed and protected linen or trash chutes.
- E
Install properly constructed and protected linen or trash chutes.
Construction1E
- E
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
·
Other homes nearby
-
St Ann Health and Rehabilitation Center
Milwaukee, WI · Champion Care
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 11 min
- Fines
- $0
-
Sunrise Health Services
Milwaukee, WI · North Shore Healthcare
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 23 min
- Fines
- $113,910
-
Mercy Health Services
Milwaukee, WI · North Shore Healthcare
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 4 h
- Fines
- $47,753