Franciscan Village

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 13, 2026

  Based on interview and record review, the facility failed to ensure a resident was provided adequate assistance during bed mobility to prevent injury. This failure resulted in R1 requiring hospitalization for treatment of a femur fracture. This applies to 1 of 3 residents reviewed for skin impairments in the sample of 5.The findings include:R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, morbid obesity, right hip osteoarthritis, dementia, and fracture of right fibula. The EMR continued to show R1 was transferred to the local hospital on March 27, 2026, and had not returned to the facility. R1's MDS (Minimum Data Set) dated January 13, 2026, showed R1 had moderate cognitive impairment. […]

• Actual harm, isolatedF689Aug 21, 2025

  Based on observation, interview, and record review, the facility failed to ensure safe transfer mobility for a resident who is dependent on staff for transfer assistance. This failure resulted to R118 falling from her wheelchair and sustaining fracture injury. In addition, the facility also failed to follow recommended transfer assistance and appropriate use of assistive devices for residents who are identified as high-risk for falls. This applies to 4 of 4 residents (R10, R43, R52, R118) reviewed for accidents and supervision in the sample of 19.The findings include:1. […]

• Actual harm, isolatedF692Aug 9, 2024

  Based on observation, interview, and record review, the facility failed to obtain monthly weights/reweights and recognize significant weight loss for a resident. This failure resulted in R82's weight loss not being recognized until R82 sustained a 12.47% weight loss in 90 days. This applies to 1 resident (R82) reviewed for weight loss in a sample of 34 residents. The findings include: On 8/6/24 at 11:57 AM, R82 said she does not like the facility food. R82 said the food is bland and I don't eat much because the food doesn't look good. R82 said she doesn't like her meat chopped up. R82 said she weighed 150 pounds when she was admitted a year ago and the last time they weighed her she was 120 pounds. R82 said she does not receive any supplements. No supplements were seen in R82's room. […]

• Actual harm, isolatedF760Jul 8, 2022

  Based on interviews and record review the facility failed to ensure that a resident's narcotic medication ([MEDICATION(S)]) was administered as ordered by the physician. This applies to 1 of 3 residents (R1) reviewed for narcotic medications. This failure resulted in R1 being hospitalized with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: R1 was admitted to the facility on [DATE], from home under hospice care with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission baseline care plan dated June 24, 2022, showed under summary that the resident was alert and oriented x 3 and was receiving hospice care. […]

• Actual harm, isolatedF689Jul 12, 2021

  Based on observation, interview and record review, the facility failed to safely transfer R1 between surfaces. The facility also failed to provide supervision to R2 during the use of the restroom. This failure resulted in R1 sustaining a clavicle fracture and shoulder separation following an unsafe transfer, and R2 sustaining a left frontal traumatic subarachnoid hemorrhage/contusion. This applies to 2 of 3 residents (R1, R2) reviewed for falls with major injury in the sample of 3. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and was discharged from the facility on June 16, 2021. […]