Franciscan Woods

FProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (May 8, 2026)

FImplement a program that monitors antibiotic use.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0881 · Deficient, Provider has date of correction (May 8, 2026)

DEnsure that residents are fully informed and understand their health status, care and treatments.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0552 · Deficient, Provider has date of correction (May 8, 2026)

DProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0628 · Deficient, Provider has date of correction (May 8, 2026)

DEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0676 · Deficient, Provider has date of correction (May 8, 2026)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Deficient, Provider has date of correction (May 8, 2026)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Deficient, Provider has date of correction (May 8, 2026)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (May 8, 2026)

DEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0693 · Deficient, Provider has date of correction (May 8, 2026)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Deficient, Provider has date of correction (May 8, 2026)

DEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (May 8, 2026)

DArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Potential for more than minimal harm · Administration Deficiencies · Tag F0849 · Deficient, Provider has date of correction (May 8, 2026)

DDevelop and implement policies and procedures for flu and pneumonia vaccinations.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0883 · Deficient, Provider has date of correction (May 8, 2026)

DEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0887 · Deficient, Provider has date of correction (May 8, 2026)

DEnsure medication error rates are not 5 percent or greater.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0759 · Complaint inspection · Deficient, Provider has date of correction (Feb 3, 2026)

DProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Deficient, Provider has date of correction (Dec 19, 2025)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Jun 2, 2025)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Jun 2, 2025)

DEnsure each resident’s drug regimen must be free from unnecessary drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0757 · Complaint inspection · Deficient, Provider has date of correction (Jun 2, 2025)

FProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Jun 2, 2025)

EDevelop and implement policies and procedures to prevent abuse, neglect, and theft.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607 · Complaint inspection · Deficient, Provider has date of correction (Apr 23, 2025)

ERespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Complaint inspection · Deficient, Provider has date of correction (Apr 23, 2025)

DHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0585 · Complaint inspection · Deficient, Provider has date of correction (Apr 23, 2025)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Apr 23, 2025)

DTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0700 · Complaint inspection · Deficient, Provider has date of correction (Apr 23, 2025)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Mar 12, 2025)

DEnsure each resident’s drug regimen must be free from unnecessary drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0757 · Complaint inspection · Deficient, Provider has date of correction (Feb 14, 2025)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Jan 23, 2025)

FProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0725 · Complaint inspection · Deficient, Provider has date of correction (Dec 10, 2024)

EProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Dec 10, 2024)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Dec 10, 2024)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (Dec 10, 2024)

DHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0585 · Deficient, Provider has date of correction (Dec 10, 2024)

DProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0623 · Deficient, Provider has date of correction (Dec 10, 2024)

DProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (Dec 10, 2024)

DImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (Dec 10, 2024)

ESafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (May 5, 2024)

ETimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Nov 4, 2023)

ERespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Complaint inspection · Deficient, Provider has date of correction (Nov 4, 2023)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Nov 4, 2023)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Deficient, Provider has date of correction (Nov 4, 2023)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Deficient, Provider has date of correction (Nov 4, 2023)

DImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (Nov 4, 2023)