Franciscan Woods

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 23, 2026

  Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 3 of 3 residents (R5, R7, and R1) reviewed for falls. *R5 was transferred by mechanical lift by one Certified Nursing Assistant (CNA.) The CNA was not following R5's care plan to transfer residents with two staff members when using a mechanical lift. R5 slid out of the sling and sustained multiple rib fractures. *R7 was transferred from bed to a motorized scooter via a sling. The sling was left under R7 while R7 was in the motorized scooter. R7 slipped out of R7's scooter and R7 sustained a right leg fracture. […]

• Actual harm, isolatedF686Dec 22, 2025

  Based on interview, and record review the facility did not ensure residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries and to promote healing for 1 (R2) of 2 residents reviewed with pressure injuries. R2 was admitted to the facility on [DATE], with a diagnosis of Type 2 Diabetes. There is no documentation the facility was performing daily diabetic foot checks as documented in R2's care plan. R2's care plan does not document person centered interventions of turning and repositioning when R2 is assessed to be dependent on the staff for activities of daily living (ADLs). On 11/1/25, R2's family notified the facility of R2 having bilateral heel pressure injuries. […]

• Actual harm, isolatedF686Mar 20, 2025

  Uncorrected on Revisit Based on observation, interview, and record review, the Facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 3 (R6, R7, R8) of 3 residents reviewed for pressure injuries. *R6 developed a deep tissue injury (DTI) which was discovered on 2/19/25 by a Licensed Practical Nurse (LPN). There is no documentation that the DTI was evaluated by a Registered Nurse until the Wound Nurse Practitioner saw it on 2/27/25. Additionally, R6 did not have nutritional interventions attempted and R6's care plan was delayed in being updated. […]

• Actual harm, isolatedF692Mar 20, 2025

  Based on observation, interview, and record review the Facility did not ensure residents maintained acceptable parameters of nutritional status for 1 (R6) of 1 resident reviewed for weight loss. R6 experienced severe weight loss over a period of 6 months, during which time R6 developed pressure injuries. The weight loss was not prescribed, and no new interventions were implemented to prevent R6's weight loss. Surveyor was unable to locate any documentation that the Facility updated the Power of Attorney or R6's physician. […]

• Actual harm, isolatedF686Feb 11, 2025

  Based on observations, interviews and record review, the facility did not ensure residents received care, consistent with professional standards of practice, and the necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing for that 1 (R3) of 3 residents reviewed for pressure injuries. * R3 did not receive pressure injury treatments for a pressure injury that was discovered during admission. There was no evidence that R3's physician was notified of R3's newly discovered pressure injury and there was a delay in implementing pressure relieving interventions and pressure injury treatments for R3. […]