Franciscan Villa

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. A quarterly assessment for Resident #3, dated 05/14/26, showed the resident had a BIMS score of 11 which indicated they were moderately impaired cognitively. The assessment showed Resident #3 was incontinent of bowel and bladder. The assessment showed Resident #3 was dependent on staff for personal hygiene.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 . Providing complete and thorough documentation of the investigation 1.A care plan for Resident #1, revised 10/10/25, showed the resident had diagnoses which included impulse disorder, persistent mood disorder, and anxiety disorder. A quarterly assessment for Resident #1, dated 03/29/26, showed the resident had a BIMS of 13 which indicated no cognitive impairment. The assessment showed Resident #1 did not have behaviors during the lookback period. An OSDH…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure the interdisciplinary team determined a resident could safely self-administer a topical medication for 1 (#2) of 6 sampled residents reviewed for medication administration.The administrator identified 86 residents resided in the facility. On 03/09/26 at 1:06 p.m., Resident #2 was observed to have antifungal cream on their bedside table.An undated Resident Self-Administration of Medication policy read in part, A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered.The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record.A physician's order for Resident #2, dated 10/12/25, showed antifungal external cream 2%. Apply to groin topically every shift for redness.A quarterly assessment, dated 12/27/25, showed that Resident #2 had a BIMS score of 13 indicating intact cognition; had diagnoses which included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. On 12/19/24 at 11:08 a.m., LPN #1 stated the treatment cart should be locked and they did not know why it was not locked. On 12/23/24 at 1:30 p.m., an unlocked/unattended treatment cart was observed on the hall. On 12/23/24 at 1:33 p.m., LPN #2 stated the treatment cart should not be left unlocked.

Based on observation and interview, the facility failed to provide palatable meals for three (#37, #23, and #4) of three residents interviewed regarding food palatability. The dietary manager identified 88 residents who ate meals prepared in the kitchen. Findings: On 12/19/24 at 10:56 a.m., Resident #37 stated the food did not taste good. The resident stated when they ate in the dining room, the food was warm but not hot; and if they ate in their room, the food was cold. On 12/19/24 at 11:11 a.m., Resident #23 stated the food tasted bad. On 12/20/24 at 8:46 a.m., Resident #4 stated the food was served to their room cold, tasted bad, and at times was inedible. The resident stated they received items on their tray which were clearly marked on their dinner card not to be served to them and when they requested an alternative item, were told the kitchen was closed. On 12/23/24 at 11:45 a.m., a test tray was checked for food palatability. The barbecued pulled pork was barely warm, the coleslaw barely cool, and the baked beans were of a good temperature but left a vinegar like after taste.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a clinical rationale when a pharmacy recommendation was declined had been provided for two (#8 and #25) of five residents who were reviewed for unnecessary medications. The DON identified 89 residents who received medications. Findings: 1. Resident #25 had diagnoses which included dementia without behavioral disturbance, anxiety, and recurrent depressive disorder. A Pharmaceutical Consultant Report, dated 05/26/22, documented the pharmacist recommended a gradual dose reduction of Celexa 20 milligrams daily. The physician declined the recommendation. There was no rationale provided on the form, physician's progress notes, or the resident's clinical record. 2. Resident #8 had diagnoses which included congestive heart failure, hypertension, and major depressive disorder. A Pharmaceutical Consultant Report, dated 05/26/22, read in parts, .Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rationale for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the kitchen failed to maintain sanitary conditions in the main kitchen, including the ice machine, the microwave in the long term care satellite kitchen, and the microwave in the resident dining room. The director of nursing identified all residents ate meals prepared in the kitchen. Findings: On 07/17/22 at 11:00 a.m., an initial tour of the kitchen was performed. There was four large packages of pork loin thawing in a box on the floor of the walk in refrigerator. There were three bottles of personal drinks in resident refrigerator labeled cooler #3. The ice machine was observed to have black, brown, and pink slimy substance scattered in, under, and around the water collection tray which holds the water to be pumped up and recirculated to freeze into ice. On 07/17/22 at 10:20 a.m., the cook was asked how often the ice machine was cleaned. The cook stated they were to clean the ice machine weekly but did not know when the ice machine had last been cleaned. They stated it had obvious been awhile since the ice machine was cleaned. On 07/17/22 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to identify significant weight loss for one (#62) of 18 residents whose comprehensive assessments were reviewed. The director of nursing identified four resident with significant weight loss. Findings: The admission assessment, dated 03/24/22 documented Resident #62 was 59 inches tall (4 foot 11 inches) and weighed 107 pounds. The assessment documented the resident had no weight loss or gain. The quarterly assessment, dated 06/22/22 documented the resident weighed 94 pounds. The assessment documented the resident had no weight loss or gain. There was a significant weight loss of 11% from the admission assessment weight of 107 pounds on 03/24/22 to the quarterly assessment weight of 94 pounds on 06/22/22 (approximately three months.) On 07/20/22 at 5:30 p.m., the director of nursing was provided the recorded weights for the admission assessment and quarterly assessment for resident #62 and asked why the resident was not identified as having significant weight loss. The director of nursing stated she did not know the assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure catheter care was documented, order was obtained, and a diagnoses was documented for the use of an indwelling urinary catheter for one (#30) of four sampled residents who were reviewed for indwelling urinary catheter use. The Resident Census and Conditions of Residents form documented five residents who had an indwelling urinary catheter. Findings: An undated policy, titled Appropriate Use of Indwelling Catheters, read in part, .The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnoses or clinical condition making the use of the catheter necessary . Resident #30 had diagnoses which included Parkinson's disease. The resident's admission assessment, dated 05/23/22, documented the resident was cognitively intact for daily decision making, was frequently incontinent of urine, and did not have an indwelling urinary catheter. Review of the electronic medical record did not reveal documentation of catheter care. The Order Summary Report, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure infection control was maintained during wound care for one (#57) of two sampled residents who were observed during wound care. The Resident Census and Conditions of Residents form identified ten residents who had pressure ulcers. Findings: Resident #57 had diagnoses which included a venous wound to the left and right calf. On 07/18/22 at 10:50 a.m., LPN #2 was observed to provide wound care to resident #57's bilateral lower extremity in the dining room. LPN #2 was observed to sit on the floor and place a piece of wax paper on the floor. The gloves were observed to hang off of the wax paper and touch the floor. The nurse was observed to cut the soiled dressing off of the resident's right leg and place the soiled scissors on top of the pile of unused gloves. The nurse was observed to leave the area and gather supplies. While the nurse was away from the resident, the resident placed their left foot onto the wax paper and dressing supplies stored on the floor atop the wax paper. LPN #2 returned and donned gloves without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.