Wheaton Franciscan HC - Terrace at St Francis

In the surveyor’s words

From the most serious findings on record at Wheaton Franciscan HC - Terrace at St Francis, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 17, 2024

  Based on record review and interviews, the facility did not ensure staff followed a resident's plan of care for transfers for 1 (R5) of 3 residents reviewed for transfers. The facility staff did not report or investigate a resident's fall to determine causative factors and did not implement preventative measures for 1 (R2) of 3 residents reviewed with falls. * On 12/11/23, R5 was transferred with 1 staff instead of 2 staff as identified on R5's care plan, and with a Hoyer lift sling that was not the appropriate size, resulting in a fall from the Hoyer lift and death. R5's plan of care was not followed regarding sling size and the need for 2 staff assistance for transfers. […]

• Actual harm, isolatedF689Oct 29, 2025

  Based on observation, interview, and record review, the facility did not ensure 3 (R3, R1, and R6) of 5 Residents received adequate supervision and assistive devices to prevent accidents. *R3 sustained a left femur fracture when CNA-P transferred R3 alone when R3 was to be a two person transfer and the sit-to-stand lost power. During the survey, R3 was observed not have the leg brace on at all times per physician orders, a follow-up x-ray of the left femur was not obtained, and Certified Nursing Assistants (CNA-F and CNA-G) were observed not operating the mechanical lift correctly when transferring R3. *R1's floor mat was not down next to the bed per care plan during the survey process. *R6's fall interventions were not followed for toileting after meals. […]

• Actual harm, isolatedF686Apr 1, 2025

  Based on observation, interview, and record review, the facility did not ensure residents received care consistent with professional standards of practice to prevent development of pressure injuries or received care to promote healing and prevent new ulcers from developing for 4 (R4, R16, R13, and R9) of 4 residents reviewed with pressure injuries. *R4 did not have skin assessments completed timely when readmitted to the facility with the development of pressure injuries. Treatments were not initiated when ordered or completed as ordered, and weekly comprehensive assessments of the pressure injuries were not documented. Surveyor observed R4 with a pressure injury to the right buttock that the facility staff was not aware of. […]

• Actual harm, isolatedF690Apr 1, 2025

  Based on interview and record review, the facility did not ensure 1 (R24) of 1 resident reviewed for a suprapubic catheter received appropriate treatment and services related to catheter care. * R24 has physician orders in place for catheter care and the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed many dates care was not documented as provided. R24 has been treated for urinary tract infections (UTIs) four times in the last six months, in addition to the prophylactic antibiotic R24 has physician orders to receive twice daily to prevent UTIs. Findings include: The facility procedure titled Catheter Care, Urinary last approved 1/2024, states in part: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections . […]

• Actual harm, isolatedF684Jul 22, 2024

  Based on interview and record review, the facility did not ensure that based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 (R13 & R25) of 12 residents. * R13 was admitted to the facility on [DATE]. R13's treatments for surgical pin sites didn't start until 3/31/24 and the left heel did not start until 3/30/24. The facility did not follow the treatment recommended by the hospital for the pin sites and the nurse who wrote the order is no longer at the facility. There are no assessments for the left heel after 4/5/24, the left upper thigh after 4/1/24, and there are no assessment for the left ankle pin site. […]