Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Franciscan Health Care Center during CMS and state inspections, most recent first.
Failure to provide nail care for residents needing ADL assistance. A resident with stroke-related impairment, a resident with DM and RA, and a resident with weakness and cognitive impairment were observed with long, dirty fingernails over multiple days. Staff gave conflicting accounts about whether CRCAs or nurses were responsible for nail care, and the facility had no policy for trimming or cleaning nails. The residents stated they wanted their nails cleaned and trimmed, but this had not been done.
Medication administration errors exceeded the allowed rate, with multiple observed failures involving insulin, eye drops, and oral medications. An RN did not prime an insulin pen before injection, another RN failed to give ordered artificial tears and gave eye drops in both eyes instead of one, a second RN omitted another ordered eye drop, and an RN gave Synthroid late and did not administer polyethylene glycol. Staff interviews showed inconsistent understanding of medication timing and administration requirements.
A resident with COPD and intact cognition was observed keeping an inhaler at the bedside and stated she used it on her own once daily. Although the physician order allowed the inhaler to be kept at the bedside, the EMR had no documented self-administration assessment, and facility leadership stated the required assessment and physician notification were not completed.
The facility failed to issue SNF ABNs to two residents when Medicare Part A skilled services were ended even though benefit days remained. One resident had intact cognition and diagnoses including DM2, bipolar disorder, anxiety, and depression; the other had acute respiratory failure with hypoxia, COPD, hypertensive heart disease with HF, and DM2. Records showed both residents still had Medicare days available, but staff documented that no ABN was given because they were not aware the Part A ABN was required.
Failure to Timely Report Allegation of Abuse: A resident admitted with acute respiratory failure with hypoxia, COPD exacerbation, and C. diff reported that a CRCA yelled at him after he activated his call light. Facility leadership treated the concern as a customer service issue rather than an abuse allegation and did not timely report it as required by policy, despite the resident stating he had been yelled at and was not satisfied with the explanation that the staff member was only speaking loudly.
Failure to obtain an order for supplemental O2 for a resident with COPD, acute and chronic respiratory failure, and pulmonary fibrosis. The resident had documented baseline home O2 use and was observed receiving oxygen at varying flow rates, including 3.5 L, but the active physician orders contained no oxygen order. Facility notes and assessments referenced SOB and continuous O2 use, yet the order was not present.
A resident with arthritis and CVA was observed using quarter bed rails on both sides of the upper bed to help sit up, but the facility had no assessment, consent, or active order for bed rail use. The resident had intact cognition and needed partial to moderate assistance with bed mobility and transfers, yet the MDS, care plan, and facility documentation did not address bed rails as required by policy.
Medication carts were found unclean and disorganized, with loose pills, debris, spilled medication, and an insulin bottle left outside the cart. Two residents' eye drops were observed without opened dates, and staff interviews showed inconsistent understanding of who was responsible for cart cleaning and dating opened meds. The facility policy required medication storage areas to be clean and opened meds such as eye drops to be dated.
Glucometer Not Disinfected After Each Resident Use: Staff failed to clean and disinfect a glucometer after use on a resident with DM and diabetic CKD. An RN placed the dirty meter into a basket with finger stick supplies, carried it into another resident’s room, and returned it to the med cart without cleaning it first. The RN stated he cleaned the meter only three times a day, not after each resident use as required by the manufacturer’s instructions.
A resident with multiple comorbidities and limited mobility did not receive thorough and timely skin assessments as required by facility policy, resulting in the development of multiple deep tissue injuries. Despite being identified as at risk for pressure ulcers and having interventions in place, documentation and staff interviews revealed gaps in assessment and care, leading to significant pressure injuries that required further medical attention.
Failure to Provide Nail Care for Residents Needing ADL Assistance
Penalty
Summary
The facility failed to ensure necessary nail care was provided for residents who were unable to complete their own ADLs for 3 of 35 sampled residents. The report states the facility did not have a policy related to trimming or cleaning residents’ nails, while the CRCA checklist and job description indicated staff were responsible for grooming and assisting with nail care, including clipping, trimming, and cleaning finger and toenails for non-diabetic residents. Staff interviews showed confusion about whether CRCAs or nurses were responsible for nail care, especially for residents with diabetes. Resident 100 was admitted with diagnoses including cerebral infarction, right lower leg fracture, CHF, anxiety, and depression, and the record showed he required assistance with ADLs. Observations over several days showed long fingernails with a black substance under the nails, and the resident stated he had asked staff to trim his fingernails but no one had done so. A CRCA stated residents’ nail care was provided with showers and as needed, but also acknowledged Resident 100’s fingernails were long and dirty and had not been cared for that week. Resident 81 was admitted with rheumatoid arthritis and type 2 diabetes mellitus, had a BIMS score of 15, and required supervision or touch assistance for personal hygiene. His care plan directed staff to provide nail care on shower days and as needed, yet observations showed long fingernails with a dark brown/black substance under them, and the resident said he wanted staff to clean and trim them. Multiple staff members stated nurses were responsible for diabetic residents’ fingernails, while others said CRCAs should clean non-diabetic residents’ nails; Resident 91, admitted with adult failure to thrive and weakness and assessed as needing supervision or touch assistance for personal hygiene, was also observed with long fingernails and dark substance under them, and stated staff had not offered to clean or trim them.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5%, with 6 errors out of 30 opportunities for a 20% error rate involving 4 residents during observed medication administration. The facility policy required the five rights of medication administration and a triple check process, and the insulin pen instructions required priming before each injection. During observation, an RN did not prime a resident’s insulin pen before giving insulin lispro, and another RN also failed to prime the insulin pen before dialing the ordered dose. Staff later stated the pen should be primed with two units, but the observed administrations did not follow that process. For one resident with orders for artificial tears and dorzolamide eye drops, an RN did not administer the artificial tears and gave dorzolamide in both eyes instead of only the left eye as ordered. The RN confirmed both errors during interview and stated she should have read the order completely and checked the MAR to ensure all medications were given as ordered. For another resident with an order for dorzolamide-timolol eye drops in both eyes once daily, an RN failed to administer the medication during observation and later stated she should have checked and double checked the MAR to ensure all medications were given as ordered. For a fourth resident, an RN administered Synthroid about an hour late and did not give the ordered polyethylene glycol. The RN stated medications should be checked against the computer and the right resident, medication, dose, time, and route verified at least twice, and confirmed the polyethylene glycol was not given. Staff interviews reflected differing understandings of the timing window for scheduled medications, while the NP stated Synthroid should be given on an empty stomach one hour before or three hours after a meal. The DHS and DVP stated medications needed to be given as ordered and that nurses should use the EMAR and check the rights when administering medications.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medications for 1 of 2 residents sampled for accidents, identified as R101. The resident was admitted with intact cognition, as shown by a BIMS score of 14 out of 15, and had a care plan problem area related to shortness of breath when lying flat due to COPD. The care plan directed staff to administer medications per physician order and did not include interventions for self-administration or for medications to be left at the bedside. R101 had a physician order for Trelegy Ellipta inhaler for COPD, with special instructions that the inhaler might be kept at the bedside. During observation, the inhaler was visible on the resident’s nightstand, and the resident stated she used it once daily on her own and that staff usually left it in her room for ease of use. However, the electronic medical record contained no documented assessment showing the resident had been evaluated for the ability to self-administer medications. Facility leadership stated the assessment should have been completed and that the proper process included assessing the resident and notifying the physician.
Failure to Issue SNF ABN When Medicare Part A Services Ended
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to 2 of 3 residents reviewed for beneficiary notification, including Resident 6 and Resident 108, when the facility notified them that Medicare Part A services were ending even though their benefit days had not been exhausted. The report states that SNF ABN forms are used to inform residents about care that may not be paid for by Medicare and to allow them to decide whether to continue services and assume financial responsibility if applicable. Resident 6 was admitted with diagnoses including type 2 diabetes, bipolar disorder, generalized anxiety disorder, and depression, and had intact cognition with a BIMS score of 15. The facility’s records showed the resident’s most recent Medicare stay began on 06/06/2025 and ended on 08/14/2025, with 30 days remaining in the benefit period when Part A services were terminated. Resident 108 was admitted with diagnoses including acute respiratory failure with hypoxia, COPD, hypertensive heart disease with heart failure, and type 2 diabetes, and the care plan noted a goal of returning to the previous living environment after rehabilitation. Records showed the resident had 51 days remaining when Medicare Part A services were terminated. In both cases, the facility documented that a SNF ABN was not provided because staff were not aware that the ABN for Part A needed to be issued. The Director of Social Services stated she was responsible for issuing SNF ABNs but had not been aware of the form until 08/20/2025, and facility leadership stated they expected SNF ABNs to be issued timely and according to policy.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse for 1 of 1 residents reviewed for abuse, R103. Facility policy required all alleged violations involving abuse, neglect, exploitation, or mistreatment to be reported immediately, and no later than 2 hours if the event involved abuse or resulted in serious bodily injury, or no later than 24 hours if it did not involve abuse or serious bodily injury. The policy also required reporting to the Administrator and to other officials, including the State Survey Agency and Adult Protective Services, in accordance with state law. R103 was admitted with diagnoses including acute respiratory failure with hypoxia, COPD with acute exacerbation, and enterocolitis due to C. difficile. The resident’s baseline care plan noted moderate depressive symptoms and directed staff to observe mood, affect, and behaviors and provide supportive counseling as needed. During interview, R103 stated that on the night of admission a CRCA yelled at him because he was unfamiliar with the facility routine and had activated his call light. He reported the staff member told him she had many residents assigned to her and that using the call light would not get her there any quicker. The allegation was brought to the facility’s attention when the SSA Surveyor reported R103’s statement to the Administrator. Facility leadership then discussed the concern with the resident and staff, but determined it was a customer service issue rather than abuse and did not report it as an allegation of abuse at that time. Interviews with the DHS, ADHS, DSS, and DVP showed the facility viewed the event as the staff member speaking loudly rather than yelling, while R103 stated he had been yelled at and was not satisfied with that explanation. The facility later documented the concern in its resident concern log and reported a separate allegation voiced by R103 on the surveyor’s follow-up, but the initial allegation of abuse was not timely reported.
Failure to Obtain Oxygen Order
Penalty
Summary
The facility failed to obtain a physician order for supplemental oxygen for one resident with COPD, acute and chronic respiratory failure with hypoxia and hypercapnia, and pulmonary fibrosis. The resident was admitted with a history of baseline oxygen use at 4 liters per minute in the hospital, and the admission MDS documented shortness of breath when lying flat, but oxygen use was not identified in the assessment. The care plan addressed the resident’s potential for shortness of breath and included directions for staff to administer oxygen per physician orders and as needed. Despite this, the resident’s active physician orders did not include an order for oxygen. Facility documentation showed intermittent oxygen administration with recorded flow rates ranging from 2 to 3 liters, and observations on two separate occasions showed the resident receiving supplemental oxygen at 3.5 liters while lying flat and while seated in a recliner. Progress notes also documented the resident on continuous oxygen at home-use requirements, including 4 liters via nasal cannula, and noted oxygen use with reference to physician orders for liter flow and delivery method.
Bed Rails Used Without Assessment or Consent
Penalty
Summary
The facility failed to ensure a resident was assessed for bed rail use and that consent was obtained before quarter bed rails were used on both sides of the upper bed. The facility policy titled, Guidelines for the Use of Bed Rails, required alternatives to be attempted first, followed by a bed rail assessment that reviewed risks including entrapment, informed consent from the resident or representative, proper installation and maintenance of the bed rails, and inclusion of bed rail use in the care plan. Resident R101 was admitted with diagnoses including arthritis and CVA. The admission MDS showed a BIMS score of 14 out of 15 and indicated the resident required partial to moderate assistance with bed mobility and transfers. The MDS did not assess bed rails as a restraint during the look-back period, the care plan did not address bed rail use, and there was no active order for bed rails. During observation, R101 was lying in bed with the head of bed elevated and quarter bed rails up on both sides, and stated she used the bed rails to sit up in bed. The DHS stated the facility had no assessment or consent for the bed rails, and other interviews confirmed the facility expected an assessment, physician order, and care plan entry for bed rail use.
Medication Carts Not Clean or Properly Labeled
Penalty
Summary
The facility failed to ensure medication carts were clean, organized, and that opened medications were labeled with an opened date on 5 of 5 medication carts observed, including the Downtown, Berry, Bell 1, Bell 2, and TCU 1 carts. Review of the facility policy on medication storage stated medication storage areas were to be kept clean, well-lit, and free of clutter, and that certain medications, including eye drops, required a date opened sticker when opened. The report also noted that 10 medication carts were located in the facility. During medication administration observations, a bottle of latanoprost eye drops for one resident and a bottle of dorzolamide eye drops for another resident did not have opened dates on them. The pharmacy date on the latanoprost box was 07/28/2025. Observation of the Downtown cart revealed loose pills, pill powder, debris, and spilled liquid medication in the drawers. The Berry cart had a bottle of Humalog insulin left on top of the cart in the basket with glucometer and blood sugar supplies. The Bell 1 cart had six loose pills in a drawer, the Bell 2 cart had a loose pill and pill powder and debris in the drawers, and the TCU 1 cart had broken pill pieces, debris, and a sticky substance in the bottom drawer. Staff interviews indicated responsibility for cleaning and organizing the carts was shared or assigned to night staff, and multiple staff stated medications such as eye drops, inhalers, and insulins should be dated when opened.
Glucometer Not Disinfected After Each Resident Use
Penalty
Summary
The facility failed to ensure staff cleaned and disinfected glucometers after use for 1 of 2 residents observed for glucometer checks, out of a total sample of 35. The facility policy titled, Glucometer Cleaning and Control Test Guidelines, stated that if glucometers were used from one resident to another, they should be cleaned and disinfected after each use and that the manufacturer’s guidelines should be followed. The manufacturer’s instructions for the Assure Prism multi Blood Glucose Monitoring System stated the meter was to be cleaned and disinfected after use on each resident, using Super Sani-Cloth Germicidal Disposable Wipes with the entire surface wiped vertically and horizontally, then left wet for 1 minute before drying. Resident #21 was admitted with a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease. The resident’s MDS assessment showed a BIMS score of 14 out of 15, indicating intact cognition, and the care plan included monitoring blood sugar per physician orders. During observation of RN 3 administering medication and checking blood sugar, the RN placed the glucometer into a basket of finger stick supplies without cleaning it first, then carried the basket with the dirty glucometer into another resident’s room and back to the medication cart. During interview, RN 3 stated he cleaned the glucometer three times a day after morning, lunch, and dinner glucose checks, rather than after each resident use as required by the manufacturer’s guidelines.
Failure to Prevent and Identify Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention and care for one resident identified as at risk for skin breakdown. The facility's policies required weekly skin observations by licensed nurses, daily skin checks by nursing assistants during personal care, and prompt notification of any skin impairment. Despite these policies, documentation and interviews revealed that the resident, who was admitted with multiple comorbidities and significant physical limitations, did not receive thorough and timely skin assessments. Progress notes indicated that the resident was unable to reposition independently and required a mechanical lift, yet there were gaps in the documentation of comprehensive skin assessments, particularly during the initial days following admission and while the resident was in isolation precautions. The resident's care plan identified them as at risk for pressure ulcers, with interventions such as weekly skin assessments, assistance with turning and repositioning, and heel protection. However, records showed that daily skin assessments documented no concerns, even though subsequent wound assessments identified multiple deep tissue injuries, including to the sacrum, right heel, and penis. Staff interviews confirmed that while wound care was eventually provided, initial assessments may not have been thorough, especially for areas not easily visible without repositioning the resident. The lack of early identification and intervention contributed to the development and worsening of pressure injuries. Further review of the resident's history showed that upon admission, there were no documented skin issues, but within ten days, multiple unstageable deep tissue injuries were present. Staff interviews revealed inconsistencies in the process for conducting head-to-toe skin assessments, particularly for residents with limited mobility or those in isolation. The facility's failure to consistently implement its own policies and ensure comprehensive skin assessments led to the resident developing significant pressure injuries that required further medical intervention.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Louisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Nursing And Rehabilitation Center | 2.7 mi | ★★★★★ | 1 | 0 |
| Wesley Manor | 3.2 mi | ★★★★★ | 0 | 0 |
| Little Sisters Of The Poor | 4.2 mi | ★★★★★ | 0 | 0 |
| Nazareth Home | 4.4 mi | ★★★★★ | 0 | 0 |
| Cherokee Park Rehabilitation | 4.7 mi | ★★★★★ | 0 | 0 |
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