Wheaton Franciscan Hc - Terrace At St Francis
Wheaton Franciscan HC - Terrace at St Francis in MILWAUKEE, WI — inspection on August 20, 2025.
Found 14 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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.
Respond appropriately to all alleged violations.
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].Findings:Surveyor reviewed the Facility Reported Incident (FRI) submitted to the State Agency on [DATE] regarding a discrepancy in the appearance of 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], 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] and a discard date of [DATE]. 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], at 12:40 PM, Surveyor requested the audits conducted by the Facility. NHA-A indicated she would look for the audits.On [DATE], 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], 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], at 3:13 PM, NHA-A informed Surveyor that the narcotic medication audits could not be located.On [DATE], 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.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheaton Franciscan Hc - Terrace at St Francis
3200 S 20th St Milwaukee, WI 53215
SUMMARY STATEMENT OF DEFICIENCIES
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.
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.
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.
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.
documents “Toileting upon rising, before meals, after meals and before bed time, whenever seeming anxious.” Surveyor requested R27’s Care Plan from the Facility.
Surveyor reviewed the Facility provided document titled “Care Plan” for 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 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 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 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 R27’s fall on 8/10/2025.
Surveyor inquired on what interventions were implemented into the care plan and if R27 had received therapy evaluation, per the RCA report. NHA-A and DON-B indicated 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheaton Franciscan Hc - Terrace at St Francis
3200 S 20th St Milwaukee, WI 53215
SUMMARY STATEMENT OF DEFICIENCIES
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.
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.
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.
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheaton Franciscan Hc - Terrace at St Francis
3200 S 20th St Milwaukee, WI 53215
SUMMARY STATEMENT OF DEFICIENCIES
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.
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 (R32 and R9) of 6 residents receiving medications.
The facility medication error rate was 18.52 percent.*R32 was given 15 milliliters (ml) of liquid Potassium Chloride, but is only ordered to receive 3.75ml. 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.*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 R9's medications.
Surveyor noted that 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 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 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 R32 had a tube feeding running through R32's enteral tube. LPN-E stopped R3's feeding and disconnected the feeding. LPN-E then used a 60ml syringe to administer the medications through R32's enteral tube.
Surveyor noted LPN-E did not flush R32's enteral tube prior to the administration of R32's medications.
Surveyor asked if R32 receives a flush after the administration of medications through R32's enteral tube.
LPN-E informed Surveyor that 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 R32's room at 9:01 AM and administered a manual water flush through 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 R32's and R9's Physician orders.
Surveyor noted 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 R32. LPN-E indicated that 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.
Facility ID: