Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Wheaton Franciscan HC - Terrace at St Francis
MILWAUKEE, WI · 81 certified beds · Last Life Safety survey August 20, 2025
CMS Certification Number 525552 · first certified September 1994
Ownership
Operated by ASCENSION LIVING · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WI
23 citations — more than 67% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 8.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens September 2026. This facility’s last Life Safety survey was August 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 23 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
9 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 23 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 1, 2023 | 6 |
| July 22, 2024 | 11 |
| August 20, 2025 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-08-20 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2025-08-20 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-08-20 |
| K-0541 | Install properly constructed and protected linen or trash chutes. | 2 | 2024-07-22 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-08-20 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2024-07-22 |
| K-0711 | Provide a written emergency evacuation plan. | 1 | 2024-07-22 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2024-07-22 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Miscellaneous Deficiencies 5
- Smoke Deficiencies 5
- Emergency Preparedness Deficiencies 3
- Other 5
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Miscellaneous Deficiencies | 5 |
| Smoke Deficiencies | 5 |
| Emergency Preparedness Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Services Deficiencies | 2 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 20, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (September 17, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 17, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 17, 2025) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (September 17, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 17, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 17, 2025) |
July 22, 2024 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (August 19, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Waiver has been granted (November 8, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (August 19, 2024) |
April 1, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (May 4, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 4, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 4, 2023) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (May 4, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 4, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (May 4, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.