Cycle 1
Health 2025-08-20 · Fire 2025-08-20
39 health deficiencies
Top issue: Quality of Life and Care (16 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Milwaukee, WI
Wheaton Franciscan Hc - Terrace At St Francis
1-star overall rating with 1-star inspections with $175,897 in total fines with 39 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
3200 S 20th St, Milwaukee, WI
(414) 389-3200
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
81
Certified beds
Average residents
40
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ascension Living
Operator or chain grouping
Approved since
1994-09-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.78
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.49
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.78
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
85%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,917
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9885
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.61
Baseline 20.48% · Performance 18.83% · Measure score 5.61 · Achievement 5.61 · Improvement 4.28
Healthcare-associated infections
6.03
Baseline 6.10% · Performance 6.03% · Measure score 6.03 · Achievement 6.03 · Improvement 0.11
Total nurse turnover
0
Baseline 69.66% · Performance 74.12% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.21
Baseline 4.14 hours · Performance 3.71 hours · Measure score 2.21 · Achievement 2.21 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.05% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 137 · Observed rate 11.68% · Lower 95% interval 7.51% |
| Discharge to community | 50.91% |
50.57%
0.3 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 44.27% · Lower 95% interval 40.97% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 63 · Denominator 63 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 63 |
| Discharge self-care score | 63.83% |
53.69%
10.1 pts better
|
Numerator 30 · Denominator 47 |
| Discharge mobility score | 68.09% |
50.94%
17.2 pts better
|
Numerator 32 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 63 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.03% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 4.17% · Lower 95% interval 3.48% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 68 |
| Staff flu vaccination coverage | 44.04% |
42%
2 pts better
|
Numerator 48 · Denominator 109 |
| Discharge function score | 68.09% |
56.45%
11.6 pts better
|
Numerator 32 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.55% |
96.28%
0.3 pts better
|
Numerator 28 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 32.26% |
25.2%
7.1 pts better
|
Numerator 10 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
95.7%
3.6 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.1% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
95.0%
2.8 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.2%
3 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 5.3% · Q3 4.7% · Q4 5.9% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
5.0%
3.3 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 3.6% · 4Q avg 1.7% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
4.9%
3.1 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 6.2% · Q3 12.5% · Q4 8.0% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.9% |
16.6%
10.7 pts better
|
19.6%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.9% · Q3 8.8% · Q4 3.8% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
16.7%
6.2 pts better
|
16.7%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 8.0% · Q3 7.7% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.0% |
21.1%
5.1 pts better
|
16.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.4% |
17.3%
1.1 pts worse
|
14.9%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 7.7% · Q3 17.2% · Q4 27.3% · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
2.3%
1.8 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
3.0%
0.6 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 2.8% · Q3 2.4% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.3% |
25.5%
13.2 pts better
|
19.8%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 10.4% · Q3 8.8% · Q4 25.4% · 4Q avg 12.3% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
5.5%
0.6 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 7.4% · Q3 0.0% · Q4 10.2% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
86.8%
4.8 pts better
|
81.7%
9.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.5% · Q2 93.0% · Q3 96.6% · Q4 97.5% · 4Q avg 91.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.5% |
15.0%
3.5 pts worse
|
12.0%
6.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 18.4% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
82.2%
11.6 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
22.7%
1.3 pts better
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 20.4% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-22 · Fire 2024-07-22
22 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
11 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Cycle 3
Health 2023-04-01 · Fire 2023-04-01
23 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-20
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-08-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-08-20
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-08-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-17
C · Minimal harm
2025-08-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-17
C · Minimal harm
2025-08-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-17
F · Potential for more than minimal harm
2024-07-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-22
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-22
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-22
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-22
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-22
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-07-22
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-08-19
F · Potential for more than minimal harm
2023-04-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-04
E · Potential for more than minimal harm
2023-04-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-04
E · Potential for more than minimal harm
2023-04-01
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-05-04
D · Potential for more than minimal harm
2023-04-01
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-05-04
D · Potential for more than minimal harm
2023-04-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-04
D · Potential for more than minimal harm
2023-04-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Not marked corrected
D · Potential for more than minimal harm
2026-01-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
D · Potential for more than minimal harm
2026-01-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Not marked corrected
G · Actual harm
2025-10-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-20
D · Potential for more than minimal harm
2025-10-29
F585 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2025-11-20
D · Potential for more than minimal harm
2025-10-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-11-20
D · Potential for more than minimal harm
2025-10-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-20
D · Potential for more than minimal harm
2025-10-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-20
D · Potential for more than minimal harm
2025-10-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-20
D · Potential for more than minimal harm
2025-10-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-20
D · Potential for more than minimal harm
2025-10-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-11-20
D · Potential for more than minimal harm
2025-10-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-20
F · Potential for more than minimal harm
2025-08-20
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2025-09-17
F · Potential for more than minimal harm
2025-08-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-17
E · Potential for more than minimal harm
2025-08-20
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-09-17
E · Potential for more than minimal harm
2025-08-20
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-17
E · Potential for more than minimal harm
2025-08-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-17
E · Potential for more than minimal harm
2025-08-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-08-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-08-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-08-20
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-08-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-08-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-08-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-08-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-17
C · Minimal harm
2025-08-20
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-06-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-10
G · Actual harm
2025-04-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-06
G · Actual harm
2025-04-01
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-06
F · Potential for more than minimal harm
2025-04-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-06
E · Potential for more than minimal harm
2025-04-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-06
E · Potential for more than minimal harm
2025-04-01
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-01
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-01
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-05-06
D · Potential for more than minimal harm
2024-12-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-08-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-20
G · Actual harm
2024-07-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-19
G · Actual harm
2024-07-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-19
G · Actual harm
2024-07-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-22
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-22
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-22
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-22
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-22
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-22
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-07-22
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-22
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-22
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-22
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-02-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-04
J · Immediate jeopardy
2024-01-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-16
G · Actual harm
2024-01-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-16
G · Actual harm
2024-01-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-16
G · Actual harm
2024-01-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-16
G · Actual harm
2024-01-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-17
F693 · Quality of Life and Care Deficiencies
Health
Ensure 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.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-17
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-02-16
D · Potential for more than minimal harm
2023-10-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-10-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-10-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-04-01
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-01
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-01
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-01
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-01
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-01
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-18
Penalties and ownership
What sits behind the stars
$71,799
2025-04-01
Fine
Fine · fine $71,799
Fine
$0
2025-04-01
Payment Denial
Payment Denial · denial start 2025-05-02 · 4 days
4 day denial
$71,858
2024-07-22
Fine
Fine · fine $71,858
Fine
$0
2024-07-22
Payment Denial
Payment Denial · denial start 2024-08-20 · 31 days
31 day denial
$32,240
2024-01-17
Fine
Fine · fine $32,240
Fine
Ownership
Ascension Health Senior Care
5% Or Greater Direct Ownership Interest · Organization
Marthiens, Edgar
Operational/Managerial Control · Individual
Musgrave, Lisa
Corporate Director · Individual
Shadbolt, Erin
Corporate Director · Individual
Sidhu, Sarfraz
Operational/Managerial Control · Individual
Smoot, Kenneth
Corporate Director · Individual
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#2
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#3
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3-star overall rating with 3-star inspections with $47,753 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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