Franklin Restorative Care Center

In the surveyor’s words

From the most serious findings on record at Franklin Restorative Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Jun 23, 2026

  Based on interview, video/audio recording review and document review, the facility administration directed staff not to report or document a resident elopement. The administration's direction not to report, prevented immediate identification and correction of failures in supervision, alarm response, staff training, and elopement prevention, leaving residents exposed to continued risk of elopement and serious injury and demonstrated a breakdown of the facility's governing systems for resident protection, quality assurance, and promoted an ongoing culture of fear of the facility being shut down, retaliation and regulatory noncompliance. […]

• Immediate jeopardy, isolatedF600Jul 20, 2026

  Based on observation, interview, and document review, the facility failed to develop and implement effective interventions to prevent resident-to-resident physical abuse for 3 of 3 residents (R1, R2, and R3) reviewed for abuse. This resulted in the likelihood of serious harm, injury, or death when on 7/9/26 R1 wandered into R2's room and began choking R2, requiring staff intervention to separate the residents. After, R1 continued to exhibit wandering behaviors and on 7/15/26 R1 wandered into R3's room and the two exchanged punches before staff could intervene. These findings constituted an Immediate Jeopardy (IJ) situation. […]

• Immediate jeopardy, isolatedF689Jun 23, 2026

  Based on interview, observation and document reviews, the facility failed to adequately supervise and maintain resident safety when resident (R4), with a history of exiting the facility unsupervised, eloped through the front door of the facility, and drove an employee vehicle in the parking lot. This resulted in an Immediate Jeopardy (IJ) situation for R4. In addition, the facility failed to implement a system to ensure adequate supervision was provided for R4, when the exit alarm system panel was not labeled to alert staff to the exit door that R4 opened. […]

• Immediate jeopardy, isolatedF808Jun 2, 2022

  Based on interview and document review the facility failed to provide a physician ordered pureed diet for 1 of 1 resident (R3) with a history of dysphasia. This resulted in actual harm for R3 as he R3 choked, was unable to be revived and died as a result. The survey resulted in an immediate jeopardy (IJ) that began on [DATE] at 8:30 p.m., when the facility failed to provide the appropriate physician ordered altered texture diet (pureed). R3 was served a whole Uncrustable brand peanut butter and grape jelly sandwich on wheat bread. R3 began choking and became unresponsive. The licensed nurse performed the [MEDICATION(S)] maneuver until EMS arrived. EMS also attempted to revive R3, but were unsuccessful, R3 died . […]

• Actual harm, isolatedF689Apr 3, 2025

  Based on interview, observation, and document review the facility failed to thoroughly investigate falls, establish adequate fall prevention interventions, and follow care planned fall interventions for 2 of 3 residents (R1 and R5) reviewed for falls. This resulted in actual harm when R1 fell and required a visit to the emergency department resulting in a fractured left tenth rib. Findings include: R1's Face Sheet dated 9/30/24, indicated R1 had hemiplegia affecting her right dominant side, dementia, disorientation, and muscle weakness. R1's Fall Risk assessment dated [DATE], indicated R1 was a high risk for falls. […]