Your report for Wheaton Franciscan Hc - Terrace at St Francis
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- WisconsinLowest tier among peers321 rated homes · average 3.0★
- Milwaukee CountyLowest tier among peers32 rated homes · average 2.4★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs WI avg
- StaffingCan add or remove a star3★−0.7 vs WI avg
- Quality measuresCan add or remove a star3★−0.1 vs WI avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersWI avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 19% of peersWI avg3.7★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 33% of peersWI avg3.1★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff4.49hrsAbove 70% of peersWI avg4.19Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.78hrsAbove only 31% of peersWI avg0.96Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better68%Above only 9% of peersWI avg48%RN turnover85%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$175,897Above only 7% of peersWI avg$41,875Fines · denials3 · 2
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthApr 2023 – Oct 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Oct 29, 2025Cycle 1worst G · actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Nov 20, 2025
- F585Honor 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 RightsD · isolatedCorrected Nov 20, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 20, 2025
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 20, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Nov 20, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Nov 20, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Nov 20, 2025
- F690Provide 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 CareD · isolatedCorrected Nov 20, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Nov 20, 2025
Aug 20, 2025Cycle 1worst F · no actual harm
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Sep 17, 2025
- F729Verify 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 ServicesF · widespreadCorrected Sep 17, 2025
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 17, 2025
- F725Provide 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 ServicesC · widespreadCorrected Sep 17, 2025
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsE · patternCorrected Sep 17, 2025
- F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Sep 17, 2025
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident RightsE · patternCorrected Sep 17, 2025
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Sep 17, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Sep 17, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 17, 2025
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceE · patternCorrected Sep 17, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareE · patternCorrected Sep 17, 2025
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Sep 17, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceF · widespreadCorrected Sep 17, 2025
Jun 11, 2025Cycle 1worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 10, 2025
- F657Develop 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 PlanningD · isolatedCorrected Jul 10, 2025
Apr 1, 2025Cycle 1worst G · actual harm$71,799, payment denial
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected May 6, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareE · patternCorrected May 6, 2025
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected May 6, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected May 6, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected May 6, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 6, 2025
- F690Provide 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 CareG · isolatedCorrected May 6, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected May 6, 2025
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected May 6, 2025
- F761Ensure 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 ServiceE · patternCorrected May 6, 2025
- F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.AdministrationD · isolatedCorrected May 6, 2025
Dec 18, 2024Cycle 2worst D · no actual harm
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Jan 16, 2025
Aug 28, 2024Cycle 2worst D · no actual harm
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Sep 20, 2024
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Sep 20, 2024
Jul 22, 2024Cycle 2worst G · actual harm$71,858, payment denial
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareG · isolatedCorrected Aug 19, 2024
- Assure that each residentâs assessment is updated at least once every 3 months.Resident Assessment and Care PlanningE · patternCorrected Aug 19, 2024
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Aug 19, 2024
- F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Resident RightsD · isolatedCorrected Aug 19, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Aug 19, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Aug 19, 2024
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected Aug 19, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Aug 19, 2024
- F690Provide 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 CareD · isolatedCorrected Aug 19, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Aug 19, 2024
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Sep 20, 2024
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceE · patternCorrected Aug 19, 2024
- F758Implement 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 ServiceD · isolatedCorrected Aug 19, 2024
- F791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected Aug 19, 2024
- F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Nutrition and DietaryD · isolatedCorrected Aug 19, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Aug 19, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 19, 2024
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 19, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Aug 19, 2024
Feb 28, 2024Cycle 2worst D · no actual harm
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Mar 4, 2024
Jan 17, 2024Cycle 3worst J · immediate jeopardy$32,240
- F690Provide 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 CareG · isolatedCorrected Feb 16, 2024
- F693Ensure 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 CareD · isolatedCorrected Feb 16, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareG · isolatedCorrected Feb 16, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsG · isolatedCorrected Feb 16, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Feb 16, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Feb 16, 2024
- F947Ensure 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 ServicesD · isolatedCorrected Feb 16, 2024
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Feb 16, 2024
Oct 5, 2023Cycle 3worst D · no actual harm
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Nov 5, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Nov 5, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Nov 5, 2023
Apr 1, 2023Cycle 3worst D · no actual harm
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected May 18, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected May 18, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected May 18, 2023
- Assure that each residentâs assessment is updated at least once every 3 months.Resident Assessment and Care PlanningD · isolatedCorrected May 18, 2023
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 18, 2023
- F657Develop 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 PlanningD · isolatedCorrected May 18, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected May 18, 2023
- F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareD · isolatedCorrected May 18, 2023
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected May 18, 2023
- F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected May 18, 2023
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 18, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined4.49hrs
- Registered nursesRN hours only0.78hrs
- Licensed practical nursesLPN hours1.16hrs
- Nurse aidesCNA hours2.56hrs
- Weekend nursingAll staff on Saturdays and Sundays3.78hrs
- Wisconsin average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better68%Above only 9% of peersWI avg 48%
- RN turnoverRegistered nurses only85%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy81 certified beds · ~40 residents a day49%Above only 9% of peersWI avg 73%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $175,897In fines
- 3Fines
- 2Payment denials
- $41,875WI avg in fines
Actions on record
- Apr 1, 2025Civil money penalty$71,799
- Apr 1, 2025Denial of payment for new admissionsfrom May 2, 2025
- Jul 22, 2024Civil money penalty$71,858
- Jul 22, 2024Denial of payment for new admissionsfrom Aug 20, 2024
- Jan 17, 2024Civil money penalty$32,240
Ownership
As filed with CMSStructure
- Ownership type
- Non profit - Corporation
- Chain
- Ascension Living20 facilities in the chain2.6★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Ascension Health Senior Care
- Robin Binek
- Ryan Breedlove
- Kellie Gronefeld
- Lisa Musgrave
- Erin Shadbolt
- Kenneth Smoot
- Suresh Misra
- Edgar Marthiens
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 525552 · 3200 S 20TH ST, MILWAUKEE, WI, 53215.
- Percentiles compare this facility with every rated nursing home in Wisconsin and Milwaukee County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









