Franciscan Villa

In the surveyor’s words

From the most serious findings on record at Franciscan Villa, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 11, 2026

  Based on record review and interview, the facility failed to ensure that a resident's behavior was monitored and documented according to the physician's order for 1 (#1) of 1 sampled resident reviewed for behavior monitoring.The administrator identified 86 residents resided in the facility.An undated Suicide Threats, policy, read in part, If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. […]

• Actual harm, isolatedF692Jul 20, 2022

  Based on record review, observation, and interview, the facility failed to implement dietary recommendations for interventions in weight loss for one (#62) of four residents reviewed for significant weight loss. Resident #62 experienced 20% weight loss from 03/31/22 to 07/09/22. The director of nursing identified four residents with significant weight loss. Resident #62 was not listed among those identified with significant weight loss. Findings: Resident #62 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's progress notes, dated 03/23/22; 03/25/22; 03/29/22; 03/31/22; 04/04/22; 04/14/22; 05/11/22; 05/31/22; 06/08/22; 06/15/22; 06/30/22; and 07/14/22 all documented Resident #62 displayed no signs or symptoms of fluid volume overload. […]

• No harm, potential for more than minimal, patternF609Jun 30, 2026

  Based on record review and interview, the facility failed report no later than two hours to the OSDH and other official agencies after an allegation of abuse was made for 1 (#3) of 5 sampled residents reviewed for abuse. The DON identified 101 residents resided in the facility. Findings: An undated facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, read in part, The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required. A care plan for Resident #3, dated 09/02/20, showed the resident had diagnoses which included chronic pain syndrome, rheumatoid arthritis, and major depressive disorder. The care plan showed Resident #3 needed assistance with daily care needs. […]

• No harm, potential for more than minimal, patternF610Jun 30, 2026

  Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for 2 (#1 and #3) of 5 sampled residents reviewed for abuse. The DON identified 101 residents resided in the facility. Findings: A facility policy titled Abuse, Neglect, and Exploitation, revised 11/2024, read in part, An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur.Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations . […]

• No harm, potential for more than minimal, patternF761Dec 23, 2024

  Based on observation and interview, the facility failed to store medications within locked compartments of a medication cart on one of three halls observed for medication storage. The Director of Nursing identified three medication carts and three treatment carts which stored medications. Findings: On 12/19/24 at 10;43 a.m., an unlocked/unattended treatment cart was observed on the resident hall. From 10:43 a.m. to 10:59 a.m., multiple staff walked past the treatment cart without locking it. On 12/19/24 at 11:01 a.m., LPN #1 walked to the unlocked treatment cart and removed a pair of gloves without locking the cart. On 12/19/24 at 11:07 a.m., LPN #1 returned to the treatment cart, removed items from its drawers and walked away from the medication cart without locking it. […]