Franciscan Post-Acute Care Center

In the surveyor’s words

From the most serious findings on record at Franciscan Post-Acute Care Center, in the surveyor’s own words.

• Actual harm, patternF697Feb 3, 2022

  Based on observation, interview, and record review, the facility failed to provide pain management services consistent with professional standards of practice for one of three sampled residents (Resident 1) when Resident 1 experienced severe pain level of seven to eight (pain scale- is a tool that measures pain intensity to help assess a person's pain) from 12/23/19 through 12/28/21 as a result of a fall on 12/21/21. Licensed Vocational Nurses (LVN) 1, 2, 3 and 4 did not use a consistent and appropriate tool to assess pain, did not accurately document shift pain assessments, and did not notify the physician when pain was severe in accordance with facility policy and procedure and professional standards of practice. […]

• Actual harm, isolatedF657Jun 12, 2025

  Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for one of six sampled residents (Resident 1) when: 1. Resident 1 was admitted to the facility with diagnoses of Type 2 Diabetes Mellitus (Type 2 DM- a disorder in which blood sugar or glucose levels are abnormally high) and licensed nursing staff did not develop an individualized care plan intervention to monitor Resident 1's blood glucose levels, from 5/4/25 to 5/18/25. This failure resulted in Resident 1 experiencing significant change in condition. […]

• Actual harm, isolatedF689Feb 5, 2025

  Based on observation, interview, and record review, the facility failed to address the risk of fire while smoking for one of three sampled residents (Resident 1), when staff were aware of Resident 1's need for oxygen (a colorless, odorless gas that is essential for life), history of smoking and bringing in cigarettes and lighters into the facility and did not implement effective measures to ensure Resident 1's safety from fire. These failures resulted in Resident 1 smoking unnoticed while wearing oxygen on 2/4/25, catching fire and suffered avoidable second-degree burns (injury that damages both the outer layer of skin and part of the underlying layer) to the face and right forearm, swelling and severe pain, requiring emergency transport to a higher level of care and hospital with a Burn… […]

• Actual harm, isolatedF689Apr 17, 2024

  Based on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of nine sampled residents (Resident 1), when Resident 1 was diagnosed with dementia (a chronic or persistent disorder of the mental processes marked by memory disorder, personality changes, and impaired reasoning), and a known history of poor safety awareness and muscle weakness and contracture (shortening of muscular or connective tissue that results in deformity) of left hand; and was not supervised while she drank hot tea on 2/16/22, in accordance with comprehensive care plan which indicated Resident 1 was totally dependent on staff to eat and drink. […]

• No harm, potential for more than minimal, patternF600Jan 13, 2025

  Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Resident 1, 2 and 4) were free from abuse when: 1. Staff failed to separate Residents 1 and 2 immediately after an altercation on 12/25/24 at 3:00 p.m., then Resident 2 sat next to Resident 1 in the sunroom and scratched Resident 1 in the face while the CNA ' s back was turned. Residents 1 and 2 had a known history of verbal altercations with each other. This failure had the potential to cause both residents harm and emotional distress due to cognitive (pertaining to reasoning memory and judgement) impairments. 2. Staff did not provide adequate supervision for Resident 1 after the altercation on 12/25/24 at 3:00 p.m. […]