Wheaton Franciscan Terrace at St. Francis: Screening Failures - WI
Federal health inspectors cited the Milwaukee facility on August 20, 2025, for failing to complete required PASARR screenings, the Preadmission Screening and Resident Review process that exists specifically to identify residents with mental illness or intellectual disabilities and connect them with appropriate care. The deficiency fell under the category of resident assessment and care planning failures.
No actual harm was documented. But inspectors determined there was potential for more than minimal harm.
That distinction matters. The PASARR process is not paperwork for its own sake. It is the mechanism that determines whether a resident with schizophrenia, bipolar disorder, a developmental disability, or another qualifying condition is receiving the right level of psychiatric or specialized support inside a nursing facility. When those screenings don't happen, or don't happen correctly, residents can spend weeks or months without services they were supposed to receive, and nobody inside the building has a formal record flagging that gap.
Inspectors assigned the violation a scope and severity level of D, meaning the problem was isolated rather than widespread, and that no resident suffered documented harm as a result. It was one of 14 separate deficiencies cited during the same inspection.
Fourteen deficiencies in a single inspection is a significant number. The inspection was triggered by a complaint, meaning someone, a resident, a family member, or a staff member, contacted regulators with a concern serious enough to prompt a visit. The inspection report does not identify who filed the complaint or what it alleged. What it shows is that inspectors arrived, conducted their review, and left with citations spanning multiple areas of care.
The facility reported that it corrected the PASARR screening deficiency by September 17, 2025, less than a month after the inspection concluded.
A correction date on file does not mean inspectors verified the fix. It means the facility told regulators it had addressed the problem by that date. Whether the residents who should have been screened were subsequently screened, and whether any of them were found to need services they hadn't been receiving, is not reflected in the inspection report.
Wheaton Franciscan HC, Terrace at St. Francis is part of a larger Catholic health system operating in the Milwaukee area. The facility provides skilled nursing and rehabilitation services.
The PASARR requirement has existed for decades, originating in federal legislation designed to prevent people with mental illness or intellectual disabilities from being warehoused in nursing facilities without appropriate psychiatric care. The screening is supposed to happen before admission in most cases, with the state Medicaid agency involved in the review. When facilities skip or mishandle those screenings, the state agency never gets the referral it needs to evaluate whether the resident belongs in the facility at all, or whether they need additional services layered on top of what the nursing home provides.
For a resident with a serious mental illness, that gap can be the difference between receiving psychiatric consultation, behavioral support, or medication management, and receiving none of it, with staff left to manage symptoms they were never formally told existed, or told existed but given no roadmap for addressing.
The inspection report does not describe which residents were affected, how many, or what conditions they carried. It does not say whether any resident experienced a behavioral crisis, a psychiatric episode, or a deterioration in mental health during the period when proper screening was absent. It records only that the screening process failed, that the potential for harm existed, and that the facility has since reported a correction.
What it does not record is what those residents experienced in the time between when the screening should have happened and when inspectors finally arrived to note that it hadn't.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wheaton Franciscan Hc - Terrace At St Francis from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
Wheaton Franciscan HC - Terrace at St Francis in MILWAUKEE, WI was cited for violations during a health inspection on August 20, 2025.
The deficiency fell under the category of resident assessment and care planning failures.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.