Wheaton Franciscan Hc - Terrace At St Francis
Inspection Findings
F-Tag F0552
Federal health inspectors cited WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS in MILWAUKEE, WI for a deficiency under regulatory tag F-F0552 during a standard health inspection conducted on 2025-08-20.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Ensure that residents are fully informed and understand their health status, care and treatments.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-17.
F-Tag F0583
Federal health inspectors cited WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS in MILWAUKEE, WI for a deficiency under regulatory tag F-F0583 during a standard health inspection conducted on 2025-08-20.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Keep residents' personal and medical records private and confidential.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-17.
F-Tag F0610
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility did not ensure that an alleged violation involving misappropriation was thoroughly investigated for 1 of 1 Facility Reported Incidents reviewed.*The facility could not provide documentation that weekly audits of narcotic medication counts were preformed, following a narcotic discrepancy identified on [DATE REDACTED].Findings:Surveyor reviewed the Facility Reported Incident (FRI) submitted to the State Agency on [DATE REDACTED] regarding a discrepancy in the appearance of Resident R27's liquid Morphine (a controlled, narcotic medication), indicating the Morphine was lighter in color instead of the usual dark blue hue.The facility indicated the police were notified, the medication was removed from the medication cart, pain assessments were completed for residents, residents were interviewed as well as staff, weekly audits
during medication counts for the next six weeks and medication audit found medication were properly stored.On [DATE REDACTED], Surveyor requested the full investigation for the FRI from the Facility. The Facility provided Surveyor with the Facility's investigation.Surveyor reviewed the Facility provided document titled INVESTIGATION SUMMARY and noted the following documented, Conclusion: Based on the findings of
this investigation, there is no substantiated evidence of misuse of the resident's medication. It is plausible that the change in color was due to extended circulation of the bottle and having low volume, especially considering it is PRN medication that is not administered frequently and filled [DATE REDACTED] and a discard date of [DATE REDACTED]. We will continue to work with the Milwaukee Police Department to find out if there were any changes in concentration. To enhance monitoring and ensure the integrity of all liquid medications, the facility will implement a weekly audit, overseen by DON or a designee, during medication counts for the next six weeks. This audit will include documentation of the color and consistency of all liquid solution medications. It is also important to note that all medications, including liquid solutions, were found to be properly stored, not expired and no residents were reported to have been adversely affected. On [DATE REDACTED], at 12:40 PM, Surveyor requested the audits conducted by the Facility. NHA-A indicated she would look for the audits.On [DATE REDACTED], at 2:07 PM, Surveyor was informed by Nursing Home Administrator (NHA)-A that NHA-A had to reach out to the previous Director of Nursing (DON) and indicated DON-B is working on obtaining
the audits. On [DATE REDACTED], at 11:41 AM, Surveyor spoke with Pharmacist Consultant-H via phone. Pharmacist Consultant-H indicated that generally, liquid morphine has a blue tint, but over time the color is expected to fade, especially if the product has been open for an extended amount of time and not used.On [DATE REDACTED], at 3:13 PM, NHA-A informed Surveyor that the narcotic medication audits could not be located.On [DATE REDACTED], at 3:25 PM, Surveyor informed the NHA-A and DON-B of the concern that the narcotic audits were not located and available for review to determine if a thorough investigation into potential misappropriation of resident's medication was completed. No additional information was provided that an alleged violation involving misappropriation was thoroughly investigated.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheaton Franciscan Hc - Terrace at St Francis
3200 S 20th St Milwaukee, WI 53215
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0628
Federal health inspectors cited WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS in MILWAUKEE, WI for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2025-08-20.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-17.
F-Tag F0645
Federal health inspectors cited WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS in MILWAUKEE, WI for a deficiency under regulatory tag F-F0645 during a standard health inspection conducted on 2025-08-20.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: PASARR screening for Mental disorders or Intellectual Disabilities
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-17.
F-Tag F0684
Federal health inspectors cited WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS in MILWAUKEE, WI for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-08-20.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-17.
F-Tag F0686
Federal health inspectors cited WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS in MILWAUKEE, WI for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-08-20.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-17.
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
documents “Toileting upon rising, before meals, after meals and before bed time, whenever seeming anxious.” Surveyor requested Resident R27’s Care Plan from the Facility. Surveyor reviewed the Facility provided document titled “Care Plan” for Resident R27. Surveyor noted no dates of revisions or dates of implementation are identified on the Facility provided document.
On 08/19/2025, at 11:33 AM, Surveyor interviewed Physical Therapy Assistant-M. Physical Therapy Assistant-M indicated that Resident R27 is on hospice and therapy does not generally work with hospice patients but are able to evaluate Hospice patients with Hospice approval. Physical Therapy Assistant-M informed Surveyor that Resident R27 was last seen by Speech Therapy in July 2025 but has not had an order to be seen by Physical or Occupational therapy since Resident R27’s fall.
On 08/20/2025, at 10:51 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B regarding Resident R27’s fall on 8/10/2025. Surveyor inquired on what interventions were implemented into the care plan and if Resident R27 had received therapy evaluation, per the RCA report. NHA-A and DON-B indicated Resident R27 should have been evaluated for therapy per the RCA report but would have to get back to Surveyor with more information.
On 08/20/2025, at 12:51 PM, Surveyor informed the facility of the above concerns. The facility did not comment on the concern or provide further information. No additional information was provided.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheaton Franciscan Hc - Terrace at St Francis
3200 S 20th St Milwaukee, WI 53215
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0698
Federal health inspectors cited WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS in MILWAUKEE, WI for a deficiency under regulatory tag F-F0698 during a standard health inspection conducted on 2025-08-20.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-17.
F-Tag F0725
Federal health inspectors cited WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS in MILWAUKEE, WI for a deficiency under regulatory tag F-F0725 during a standard health inspection conducted on 2025-08-20.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity Level C: pattern, no actual harm with potential for minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-17.
F-Tag F0729
Federal health inspectors cited WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS in MILWAUKEE, WI for a deficiency under regulatory tag F-F0729 during a standard health inspection conducted on 2025-08-20.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-17.
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm
information was provided as to why the facility did not provide pharmaceutical services that assure proper dispensing of medications, did not ensure drug records are in order, or all controlled drugs are maintained and periodically reconciled.
Residents Affected - Many
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheaton Franciscan Hc - Terrace at St Francis
3200 S 20th St Milwaukee, WI 53215
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0756
Federal health inspectors cited WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS in MILWAUKEE, WI for a deficiency under regulatory tag F-F0756 during a standard health inspection conducted on 2025-08-20.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of WHEATON FRANCISCAN HC - TERRACE AT ST FRANCIS.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-17.
F-Tag F0759
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview, and record review, the facility did not ensure the medication rate was not 5 percent or greater. This deficient practice was observed in 2 (Resident R32 and Resident R9) of 6 residents receiving medications. The facility medication error rate was 18.52 percent.*Resident R32 was given 15 milliliters (ml) of liquid Potassium Chloride, but is only ordered to receive 3.75ml. Resident R32 received medication through an enteral feeding tube. The Enteral Tube was not flushed prior to administering the medications and was not flushed
after administering the medications, until approximately 1 hour later.*Resident R9 was administered Insulin that was past the discard by date.Findings include:The Facility policy titled, Administering Medications dated 12/2024 documents: .C. Medications shall be administered in accordance with the orders and within the allowable time frame per best practice/regulatory guidelines. H. The expiration/beyond use date on the medication label is to be checked prior to administering. The Facility policy titled, Medication Administration vis Enteral Tube dated 12/2024 documents: . K. Procedure: . 9. Flush enteral tube with at least 15ml of water prior to administering medications unless otherwise ordered by prescriber . 13. Flush the tube with a final flush of at least 15 ml of water to ensure drug delivery and clear tube.On 08/19/2025, at 7:23 AM, Surveyor observed Licensed Practical Nurse (LPN)-E prepare Resident R9's medications. Surveyor noted that Resident R9's Insulin, Humalog (Lispro) did not have an open date on the vial but noted a discard by date of 07/15/2025
on the packaging. LPN-E administered 6 units of Resident R9's insulin despite being passed the discard date.On 08/19/2025, at 7:48 AM, Surveyor observed Licensed Practical Nurse (LPN)-E prepare Resident R32's medications.
The medications that were observed to be prepared were: -Linzess 72 micrograms (mcg)-Acetaminophen 325 milligrams (mg) x2-Drizalina 60mg-Florastor 250mgLPN-E was observed pouring a Potassium Chloride Solution 40 meq/15ml into a separate medication cup. Surveyor noted LPN-E measured out 15ml into the medication cup. LPN-E then mixed all the medications together and added water. Surveyor noted Resident R32 had
a tube feeding running through Resident R32's enteral tube. LPN-E stopped Resident R3's feeding and disconnected the feeding. LPN-E then used a 60ml syringe to administer the medications through Resident R32's enteral tube.
Surveyor noted LPN-E did not flush Resident R32's enteral tube prior to the administration of Resident R32's medications.
Surveyor asked if Resident R32 receives a flush after the administration of medications through Resident R32's enteral tube.
LPN-E informed Surveyor that Resident R32 receives preprogramed flushes every 4 hours while receiving tube feedings and is not due for a manual flush until 9:00 AM.Surveyor observed LPN-E come back to Resident R32's room at 9:01 AM and administered a manual water flush through Resident R32's enteral tube.On 08/19/2025, at 10:02 AM, Surveyor interviewed Director of Nursing (DON)-B. DON-B indicated that enteral tubes are to be flushed before and after administration of medications and that all insulins should have a open date on the vial and should be discarded by the date listed on the packaging or 28 days after the open date, which ever comes first.Surveyor reviewed Resident R32's and Resident R9's Physician orders. Surveyor noted Resident R32's order for liquid Potassium Chloride is to give 3.75ml.On 08/19/2025, at 1:09 PM, Surveyor interviewed LPN-E regarding
the amount of Potassium Chloride administered to Resident R32. LPN-E indicated that Resident R32 should have received 3.75ml per the order but was given 15ml. LPN-E then began the Facility's protocol for medication errors.On 08/19/2025, at 1:20 PM, DON-B was made aware of the medication error and assisted LPN-E with completing the facility's medication error protocol.On 08/19/2025, at 3:35 PM, Surveyor informed the facility of the medication errors observed.On 08/20/2025, at 12:51 PM, Surveyor informed Nursing Home Administrator-A and DON-B that Surveyor completed the Medication Administration observations and informed them of the concerns. No additional information was provided.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Wheaton Franciscan HC - Terrace at St Francis in MILWAUKEE, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MILWAUKEE, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Wheaton Franciscan HC - Terrace at St Francis or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.