Wheaton Franciscan HC - Terrace at St Francis

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0585 · Complaint inspection · Deficient, Provider has date of correction (Nov 20, 2025)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Nov 20, 2025)

DRespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Complaint inspection · Deficient, Provider has date of correction (Nov 20, 2025)

DProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (Nov 20, 2025)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Nov 20, 2025)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Nov 20, 2025)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Complaint inspection · Deficient, Provider has date of correction (Nov 20, 2025)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Nov 20, 2025)

FVerify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0729 · Deficient, Provider has date of correction (Sep 17, 2025)

FProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Sep 17, 2025)

EEnsure that residents are fully informed and understand their health status, care and treatments.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0552 · Deficient, Provider has date of correction (Sep 17, 2025)

EProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0628 · Deficient, Provider has date of correction (Sep 17, 2025)

EProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Deficient, Provider has date of correction (Sep 17, 2025)

EEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0756 · Deficient, Provider has date of correction (Sep 17, 2025)

DKeep residents' personal and medical records private and confidential.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0583 · Deficient, Provider has date of correction (Sep 17, 2025)

DRespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Complaint inspection · Deficient, Provider has date of correction (Sep 17, 2025)

DPASARR screening for Mental disorders or Intellectual Disabilities

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0645 · Deficient, Provider has date of correction (Sep 17, 2025)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Deficient, Provider has date of correction (Sep 17, 2025)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Sep 17, 2025)

DProvide safe, appropriate dialysis care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (Sep 17, 2025)

DEnsure medication error rates are not 5 percent or greater.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0759 · Complaint inspection · Deficient, Provider has date of correction (Sep 17, 2025)

DProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Deficient, Provider has date of correction (Jul 10, 2025)

DDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Complaint inspection · Deficient, Provider has date of correction (Jul 10, 2025)

FProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (May 6, 2025)

EProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (May 6, 2025)

EEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Complaint inspection · Deficient, Provider has date of correction (May 6, 2025)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (May 6, 2025)

DProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (May 6, 2025)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (May 6, 2025)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (May 6, 2025)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Complaint inspection · Deficient, Provider has date of correction (May 6, 2025)

DProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Potential for more than minimal harm · Administration Deficiencies · Tag F0773 · Complaint inspection · Deficient, Provider has date of correction (May 6, 2025)

DEnsure medication error rates are not 5 percent or greater.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0759 · Complaint inspection · Deficient, Provider has date of correction (Jan 16, 2025)

DProvide safe, appropriate pain management for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0697 · Complaint inspection · Deficient, Provider has date of correction (Sep 20, 2024)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Sep 20, 2024)

FProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Aug 19, 2024)

FProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Aug 19, 2024)

EAssure that each resident’s assessment is updated at least once every 3 months.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0638 · Deficient, Provider has date of correction (Aug 19, 2024)

EEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0756 · Deficient, Provider has date of correction (Aug 19, 2024)

DAllow resident to participate in the development and implementation of his or her person-centered plan of care.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0553 · Complaint inspection · Deficient, Provider has date of correction (Aug 19, 2024)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Deficient, Provider has date of correction (Aug 19, 2024)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Aug 19, 2024)

DRespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Complaint inspection · Deficient, Provider has date of correction (Aug 19, 2024)

DAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0636 · Deficient, Provider has date of correction (Aug 19, 2024)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Deficient, Provider has date of correction (Aug 19, 2024)

DProvide safe and appropriate respiratory care for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Deficient, Provider has date of correction (Aug 19, 2024)

DProvide safe, appropriate pain management for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0697 · Deficient, Provider has date of correction (Sep 20, 2024)

DImplement 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (Aug 19, 2024)

DProvide or obtain dental services for each resident.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0791 · Deficient, Provider has date of correction (Aug 19, 2024)

DProvide special eating equipment and utensils for residents who need them and appropriate assistance.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0810 · Deficient, Provider has date of correction (Aug 19, 2024)

DArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Potential for more than minimal harm · Administration Deficiencies · Tag F0849 · Deficient, Provider has date of correction (Aug 19, 2024)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Mar 4, 2024)

DProvide enough food/fluids to maintain a resident's health.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0692 · Complaint inspection · Deficient, Provider has date of correction (Feb 16, 2024)

DEnsure 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.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0693 · Complaint inspection · Deficient, Provider has date of correction (Feb 16, 2024)

DEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0947 · Complaint inspection · Deficient, Provider has date of correction (Feb 16, 2024)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Nov 5, 2023)

DEnsure medication error rates are not 5 percent or greater.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0759 · Complaint inspection · Deficient, Provider has date of correction (Nov 5, 2023)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Nov 5, 2023)

DDevelop and implement policies and procedures to prevent abuse, neglect, and theft.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607 · Deficient, Provider has date of correction (May 18, 2023)

DAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0636 · Deficient, Provider has date of correction (May 18, 2023)

DAssess the resident when there is a significant change in condition

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0637 · Deficient, Provider has date of correction (May 18, 2023)

DAssure that each resident’s assessment is updated at least once every 3 months.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0638 · Deficient, Provider has date of correction (May 18, 2023)

DProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Deficient, Provider has date of correction (May 18, 2023)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Deficient, Provider has date of correction (May 18, 2023)

DEnsure medication error rates are not 5 percent or greater.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0759 · Deficient, Provider has date of correction (May 18, 2023)