Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Momentous Health At Franklin during CMS and state inspections, most recent first.
A resident on a renal diet reported not getting enough food and was observed eating from used meal trays on a food cart, while an LPN confirmed this occurred regularly. Staff also served incorrect portion sizes for tacos, prepared pureed food using an improper process, and left a posted menu outdated for several days, with the DS stating menus were not updated over the weekend.
Cold and unpalatable meals were observed and reported by residents and a resident representative. A test tray with tacos, refried beans, and rice and beans was lukewarm, and the DS verified the food was not served at a suitable temperature. Several residents reported receiving cold food, and one resident was identified as not receiving food from the kitchen.
Unsealed and undated food items were found in kitchen refrigerators, including cheese, bologna, sausage, cookie dough, and unidentified food in disposable cups. During food prep, an employee with facial hair was not wearing a beard restraint, and the DS’s hair net did not fully contain her hair. Surveyors also observed debris on a ceiling vent, black specs on the surrounding ceiling, and a dirty steam table support beam.
QAPI committee meetings did not consistently include required members. Review of sign-in sheets showed the DON and MD were absent from some meetings without listed designees, and the IP was also absent from some meetings without a designee. The facility’s policy listed several committee members and required meetings at least quarterly, but the IP was not identified as a required member. The Administrator and COO confirmed the attendance issues.
Facility failed to maintain a clean, sanitary, and safe environment. Observations found dirty floors on the 200 and 300 halls with shoe prints, wheelchair marks, dried liquid drips, dirt, grime, and dust, and a resident described the facility as "nasty." Staff confirmed the halls had not been cleaned over the weekend after most housekeeping staff were fired. In the laundry room, all three dryer lint traps had a buildup of lint, and staff verified the lint should be cleaned regularly.
Failure to follow contact isolation precautions for two residents. One resident with active shingles and open, moist blisters was observed in the dining room with other residents despite an order for contact isolation, and staff confirmed the resident should have been isolated. Another resident with HSV wounds had no contact precaution sign or PPE cart outside the room, and a CNA reported using only gloves during care despite the contact isolation order.
Failure to report alleged physical abuse: An LPN heard a resident yelling at an unknown CNA during personal care and documented that the resident hit the CNA twice. The resident later apologized, but the incident was not reported to administration or the State Survey Agency, and the SRI showed no report of the allegation. The resident had multiple diagnoses, including CVA with left-sided hemiplegia, COPD, anxiety, and chronic respiratory failure with hypoxia, and had moderately impaired cognition.
Admission comprehensive MDS assessments were not completed within required timeframes for three residents. The residents had significant medical and psychiatric diagnoses, including dementia, depression, anxiety, suicidal ideations, ESRD on dialysis, and heart failure. An MDS nurse verified the assessments were completed late and should have been finished within 14 days of admission.
Incomplete resident care plans were identified for two residents. One resident with multiple diagnoses, moderately impaired cognition, and ADL assistance needs had no care plan for ADLs or edentulism, while another resident receiving Eliquis and psychotropic meds had no care plan for anticoagulant or psychotropic use. MDS nurses confirmed the missing care plan elements, and the facility policy required comprehensive, person-centered care plans with measurable objectives and timetables.
Care plans were not updated timely for two residents to reflect changes in condition. One resident with dementia and major depressive disorder had a new Herpes Simplex 1 diagnosis and a new order for Valtrex, but the care plan did not include them. Another resident with alcohol-induced persisting dementia had increased sexual behaviors and a new order for medroxyprogesterone acetate, but the care plan also did not reflect those changes. The DON verified the omissions.
A resident with paraplegia, schizophrenia, anxiety disorder, and bipolar disorder reported there were no activities. Review of the activity schedule showed no resident activities after 2:00 P.M. on most days, except for church services every other Tuesday, and the Activities Director confirmed there were no later scheduled activities because there was not enough help in the activities dept.
A resident with centrilobular emphysema and Alzheimer's disease, moderate cognitive impairment, and a smoking assessment requiring supervision was observed lying in bed with a vape in hand and smoke above her knees. An LPN confirmed the vape was in the resident's room and not allowed there, and a CNA stated the resident was always vaping in her room. The facility's smoking policy required smoking to be limited to designated areas and strictly enforced.
Medication Error Rate Exceeded Allowed Threshold: Surveyors found a medication error rate above 5% after observing an LPN administer two wrong-dose medications to a resident. The resident received incorrect doses of calcium plus vitamin D3 and duloxetine instead of the ordered amounts, and the LPN confirmed the errors and stated the correct calcium dose was not available in the med cart.
Incomplete medical record documentation was found for a resident with ESRD on dialysis and heart failure. Staff documented a missed dialysis transport and later sent the resident to the hospital after an NP was notified, but the chart did not show physician notification for earlier missed dialysis treatments or document any physician recommendation for hospital transfer or resident refusal. The DON and COO verified the record was silent for those notifications, despite the physician stating he had been informed.
Unsafe and Unclean Resident Environment: Two residents were found in areas that were not clean or homelike. One resident’s bathroom smelled of urine and had yellow staining around the toilet base, brown marks on the floor, and staff confirmed no housekeeper had been assigned to the hall for over a month. Another resident’s room had missing floor tile pieces in the walkway and near the resident’s table; the resident had cerebrovascular disease and OCD and used a walker at times, and an LPN confirmed the damaged flooring.
Failure to provide needed nail care for a resident who required ADL assistance. The resident had intact cognition but needed supervision or limited assistance with personal hygiene and bathing, and staff documentation showed nail care had not been provided for an extended period. During observation, the resident’s fingernails were long, jagged, curling, and chipped, and the resident stated staff had not helped despite repeated requests and that carpal tunnel syndrome prevented self-care. An admissions nurse confirmed the resident needed nail care, and the facility policy required nails to be trimmed and kept neat as needed.
The facility failed to follow the planned menu for breakfast, affecting 59 residents. Regular and mechanical soft diets were served ham instead of sausage, and no substitution was provided for cheesy scrambled eggs. Pureed diets did not receive pureed bread. The facility's policy required dietician review of portion sizes, which was not followed.
The facility failed to store food items in a sanitary manner, affecting 59 residents. The reach-in refrigerator was at 60°F, above the required 41°F, with packages of ham, hamburgers, and hotdogs inside. A gray fuzzy substance was found on a line and ceiling vent, and flies were observed in the kitchen. The Dietary Supervisor confirmed the refrigerator had been broken for a week.
The facility failed to securely store medications, affecting several residents. Unsupervised wound cleansing products, misplaced medications, and expired nasal sprays were found in residents' rooms. Additionally, a treatment cart was left unlocked and unsupervised. The facility's policy requires secure storage of all drugs and biologicals, which was not adhered to, potentially affecting cognitively impaired and independently mobile residents.
A resident admitted with multiple health conditions did not have their admission assessments completed until after discharge. The assessments, including the Nursing Admission Assessment, Bowel and Bladder Assessment, and others, were delayed due to a lack of policy and oversight. Staff interviews confirmed the delay, and the facility's administrator acknowledged the expectation for timely completion was not met.
A facility failed to ensure proper hand hygiene during incontinence care for a resident with severe cognitive impairment. An STNA was observed not changing gloves or performing hand hygiene after handling a urine-soaked brief, using the same gloves to assist the resident and handle items. Interviews confirmed the STNA did not follow the facility's hand hygiene policy.
Failure to Provide Proper Meal Service and Updated Menus
Penalty
Summary
Menus were not kept current and residents were not consistently served food as planned. The facility failed to ensure posted menus were updated for residents to view the meals for the day, and the posted menu on the 200 hall was from several days earlier. A resident observed the outdated menu and stated it did not help because it was from several days ago. The dietary supervisor stated menus were not printed over the weekend and the posted menu was not updated until Monday morning. The facility also failed to ensure residents received enough food to meet their needs and preferences and that portion sizes matched the menu. Resident #3, admitted with type II diabetes mellitus, ESRD with dialysis dependence, and GERD, was on a restricted renal diet and reported sometimes not getting enough food and being supposed to receive double portions. Staff observed Resident #3 pulling food off used trays on the food service cart, and an LPN confirmed this happened all the time and that staff had not stopped it. During tray line observation, residents on the standard menu were served one taco and residents on double portions were served two tacos, although the dietary supervisor verified double portions should have received four tacos. The facility also failed to prepare pureed food according to the guidelines, as taco meat for pureed diets was processed with broth and bread crumbs before the consistency was assessed. The facility identified one resident who did not receive food from the kitchen.
Cold and Unpalatable Meals Served
Penalty
Summary
The facility failed to ensure residents received food that was palatable and served at a safe and appetizing temperature. During observation of a test tray with the Dietary Supervisor, the taco, refried beans, and rice and beans were found to be lukewarm and not palatable, and the Dietary Supervisor verified they were not served at a suitable temperature. Resident interviews also described cold meals: one resident stated lunch was cold, another said the food was cold "like it always is" and described it as "hog slop," and another resident complained of cold food. A responsible party for another resident reported that the resident often complained about the food being cold. The facility also identified one resident who did not receive food from the kitchen.
Unsealed Food, Missing Hair Restraints, and Dirty Kitchen Surfaces
Penalty
Summary
Food was stored in a manner that did not protect against the potential spread of foodborne illness. During observation of the kitchen reach-in refrigerators, a reusable plastic bag of cheese slices was found unsealed, a package of bologna slices was not dated or sealed, and a box containing two bags of sausage included one bag that was not sealed and did not have a date. In a later observation, a bag of cookie dough was found unsealed, and two plastic disposable cups containing an unidentified food were not sealed, labeled, or dated. The Dietary Supervisor verified the cheese was not sealed and the bologna and sausage were not sealed or dated, and also verified the cookie dough and the two plastic cups were not sealed, labeled, or dated. The kitchen was also observed to have staff and environmental sanitation issues during food preparation. One staff member preparing pureed taco meat had facial hair measuring approximately one-fourth inch and was not wearing any restraint for it, which the staff member verified. The Dietary Supervisor was observed standing next to that staff member while preparing food and was wearing a hair net that did not fully contain her hair, with approximately three inches sticking out. In addition, a ceiling vent above the steam table was coated in light brown debris, black specs were present on the surrounding ceiling area, and the top portion of the steam table support beam was coated in a brown and grey fuzzy substance; the Dietary Supervisor verified these areas needed cleaning and stated she was unable to reach them.
QAPI Committee Lacked Required Members at Meetings
Penalty
Summary
The facility failed to ensure that required Quality Assurance and Performance Improvement (QAPI) team members were present at QAPI/Quality Assurance and Assessment (QAA) meetings. Review of the facility’s QAPI meeting sign-in sheets showed that the DON and MD were not present at the 10/23/24 meeting, and no designees for either role were listed. The DON and MD were also not present at the 02/10/25 meeting, with no designees listed, and no staff identified as the infection preventionist (IP) or designee was present. At the 04/22/25 meeting, the DON was not present and no designee was listed. At the 08/26/25 meeting, the IP was not present and no designee was listed. Review of the facility’s QAPI/QAA policy dated 08/01/23 showed the committee members include, but are not limited to, the DON, MD or physician, Administrator, and other department leaders, and that the committee meets at least quarterly. The policy review also showed the IP was not listed as a required team member. During interview, the Administrator confirmed the QAPI meetings on 10/23/24, 02/10/25, 04/22/25, and 08/26/25 did not have the required members attending, and confirmed the IP was not listed as a required member in the facility’s policy. The Chief Operating Officer also confirmed the same meeting attendance concerns.
Facility Failed to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and safe environment for residents, staff, and the public. On the 200 and 300 halls, observations showed numerous dark grey and black shoe prints, wheelchair trail marks, and marks suggestive of dried liquid drips on the floors, along with dirt, grime, and dust throughout both halls. Resident #31 described the facility cleanliness as "nasty" and stated that all but one of the housekeepers had recently been fired. Resident #4 also stated the common area floors were not very clean and believed they were dirty because there was only one housekeeping person for the entire building. Housekeeper #109 verified the condition of the 200 and 300 halls and stated the halls had not been cleaned over the weekend because the majority of the housekeeping staff had recently been fired. In the laundry room, all three dryer lint traps were observed to have a buildup of lint. Housekeeper #126 verified the lint buildup would come from a couple loads and stated she had just started her shift and was doing her first load of laundry for the day. The facility policy titled "Infection Control – Housekeeping" stated the procedure is to provide safe and septic handling, washing, and storage of linens.
Failure to Follow Contact Isolation Precautions
Penalty
Summary
The facility failed to follow physician-ordered contact isolation precautions for Resident #13 and Resident #57. Resident #13 had an admission date of 12/14/11 and diagnoses including cerebrovascular disease, obsessive-compulsive disorder, and hemiplegia and hemiparesis following an unspecified cerebrovascular disease affecting the right dominant side. A physician order dated 09/09/25 required contact isolation precautions every shift for shingles until resolved. On 09/09/25 at 11:16 A.M., Resident #13 was observed sitting in the dining room, leaning on a dining room table, with ten other residents and one CNA present. An LPN confirmed that Resident #13 was positive for shingles, had open and moist blisters, and should have been in contact isolation, and also confirmed the resident should not have been in the dining room with other residents due to active shingles. An activities staff member stated she was not aware that Resident #13 required contact isolation and that this had not been communicated to her. Resident #57 had an admission date of 04/18/22 and diagnoses including cerebral infraction and dementia. A physician order dated 08/21/25 required contact isolation precautions due to wounds from herpes simplex virus. On 09/08/25 at 9:19 A.M., Resident #57's room did not have a sign indicating contact precautions before entry and did not have a PPE supply cart outside the room. An LPN verified the lack of signage and PPE outside the room, and a CNA stated she had recently been alerted to the contact isolation order and that while providing care that morning, she only used gloves. The facility policy stated that when a resident has contact precautions, a gown should be worn when entering the room and the facility will implement a system to alert staff to the precautions.
Failure to Report Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure an alleged staff-to-resident physical abuse incident was reported timely to administration and the State Survey Agency. Resident #40 was admitted on 06/09/25 and had diagnoses including cerebral infarction with left-sided hemiplegia, COPD, hypertension, anxiety, and chronic respiratory failure with hypoxia. The quarterly MDS indicated moderately impaired cognition. On 07/01/25 at 6:05 A.M., an LPN entered the resident’s room and heard the resident yelling profanities and telling an unknown CNA to get off of her while the CNA was providing personal care. The LPN documented that the resident hit the CNA twice, asked what happened, and the resident did not provide an answer at that time. Approximately 20 minutes later, the resident apologized and stated she was in her sleep. Review of the facility’s SRI from 07/01/25 through 09/10/25 showed no allegation of physical abuse involving Resident #40 was reported to the State Survey Agency. The Administrator stated on 09/09/25 that she was not aware of the allegation and did not report it to the State Survey Agency. The LPN later stated she could not remember the CNA involved but recalled asking the CNA to leave the resident’s room, and she confirmed she did not report the incident to administration. The facility policy titled Abuse Prevention stated that all alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property, including injuries of unknown source, are to be investigated and that staff should report all incidents or allegations immediately to the administrator or designee.
Late Completion of Admission MDS Assessments
Penalty
Summary
The facility failed to ensure admission comprehensive MDS assessments were completed within the required timeframe for three residents reviewed for resident assessment. Resident #39 was admitted with diagnoses including major depressive disorder, anxiety disorder, suicidal ideations, hypertension, and morbid obesity, and the admission comprehensive MDS assessment was not locked as completed until more than a month after admission. MDS Nurse #172 verified that the assessment should have been completed within 14 days of admission. Resident #25 was admitted with diagnoses including dementia, anxiety, and depression, and the admission comprehensive MDS assessment was not locked as completed until after the required completion date. Resident #3 was admitted with diagnoses including cellulitis, depression, viral hepatitis C, end-stage renal disease with dependence on renal dialysis, anxiety, gastroesophageal reflux disease, and heart failure; the resident also transferred to the hospital and was readmitted to the facility, and the admission comprehensive MDS assessment was not completed within 14 days of admission. MDS Nurse #172 verified that the assessment for Resident #3 should have been completed by the required deadline.
Incomplete Resident Care Plans
Penalty
Summary
Resident #3’s care plan was incomplete after admission on 05/21/25 and following a hospital transfer and readmission. The resident’s diagnoses included cellulitis, depression, type II diabetes mellitus, history of nontraumatic intracerebral hemorrhage, end-stage renal disease with dependence on renal dialysis, anxiety, gastroesophageal reflux disease, and heart failure. Review of the plan of care dated 05/29/25 showed no care plan addressing the resident’s ability to carry out activities of daily living (ADLs) and no dental care plan for edentulism. The quarterly MDS assessment showed moderately impaired cognition, that the resident was independent or needed supervision for all ADLs, and required supervision and touching assistance with walking up to 50 feet. MDS Nurse #178 confirmed the care plan did not address ADLs or edentulism. Resident #55’s record showed diagnoses of traumatic subdural hemorrhage without loss of consciousness and major depressive disorder. Physician orders included Mirtazapine 7.5 mg at bedtime for major depressive disorder, Celexa 10 mg at bedtime for major depressive disorder, and Eliquis 5 mg twice daily for acute embolism and thrombosis of the deep vein of the left lower extremity. Review of the care plans showed no care plan for anticoagulant use or psychotropic medications. MDS Nurse #172 confirmed the resident did not have a care plan for anticoagulants or psychotropic medications. The facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident.
Care plans not updated for new diagnoses, behaviors, and medications
Penalty
Summary
The facility failed to ensure care plans were updated in a timely manner to reflect changes in residents’ conditions, including new diagnoses, new sexual behaviors, and medications ordered to treat those conditions. Based on medical record review, staff interview, and policy review, this affected 2 of 6 residents reviewed for care planning in a facility with a census of 66. The facility policy stated that assessments are ongoing and care plans are revised as information about the resident and the resident’s condition changes. For one resident, the record showed diagnoses including cerebral infraction, dementia, and major depressive disorder, and the resident was cognitively impaired on MDS assessment. Laboratory records showed a positive Herpes Simplex 1 result, and the physician ordered Valtrex 500 mg. The care plan reviewed on 09/10/25 did not include the new diagnosis or the medication. For another resident, the record showed diagnoses including alcohol dependence with alcohol-induced persisting dementia, and nursing notes documented increased sexual behaviors. The physician ordered medroxyprogesterone acetate 5 mg for the behaviors, but the care plan did not include the sexual behaviors or the new medication. The DON verified that both care plans were not updated timely and should have included the new diagnoses, behaviors, and medications.
Activities Not Scheduled Throughout the Day
Penalty
Summary
The facility failed to ensure activities met the needs and preferences of residents, affecting Resident #77, who was admitted with diagnoses of paraplegia, schizophrenia, anxiety disorder, and bipolar disorder. Resident #77 stated there were no activities. Observation of the September 2025 activity schedule showed no activities scheduled for residents after 2:00 P.M. each day of the month, except for church services every other Tuesday at 6:00 P.M. The Activities Director confirmed there were no scheduled activities after the 2:00 P.M. activity was completed, except for the church services, and stated there was not enough help in the activities department and she was trying to find help. The facility policy stated activities would be scheduled periodically during the day, as well as during the evenings, weekends, and holidays.
Resident Vaped in Room Despite Supervision Requirement
Penalty
Summary
The facility failed to ensure a resident vaped only in the designated smoking area and failed to maintain adequate supervision related to smoking. Resident #11 was admitted with diagnoses including centrilobular emphysema and Alzheimer's disease. The annual MDS indicated moderate cognitive impairment, that the resident rejected care at times, and that the resident was independent with ambulation. The smoking assessment stated the resident required supervision while smoking, and there was no documentation that the resident was non-compliant with the facility's smoking policy. During observation and interview, Resident #11 was found lying in bed with a cloud of smoke above her knees and a vape machine in her left hand. The resident stated it was nothing. An LPN confirmed at the time of observation that the resident had the vape in her room and was not allowed to have a vape in her room. The DON then went to the room, spoke with the resident, and removed the vape. A CNA stated the resident was always vaping in her room. The facility's smoking policy required safe resident smoking practices, designated smoking area signs, strict enforcement of smoking restrictions in nonsmoking areas, and periodic checks for smoking articles in violation of policy. FDA guidance cited in the report stated there are no safe tobacco products, including ENDS, and noted reports of overheating, fires, and explosions associated with vaping products.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure the medication error rate did not exceed five percent. During observation, staff interviews, and policy review, surveyors found two medication errors out of 34 opportunities, resulting in a 5.88% medication error rate. This involved one resident out of four residents reviewed for medication administration, with the facility census at 66. Review of the medical record for the resident showed an admission date of 12/20/21 and physician orders for Calcium plus Vitamin D3 Oral Tablet 500-5 mg-mcg, one tablet by mouth daily, and Duloxetine HCl oral capsule delayed release sprinkle 30 mg, one capsule by mouth daily. During observations on 09/10/25, an LPN administered 33 medications to three residents and gave the resident Calcium + Vitamin D3 Oral Tablet 600-10 mg-mcg, one tablet by mouth, and Duloxetine HCl oral capsule delayed release sprinkle 20 mg, one capsule by mouth, instead of the ordered doses. In interview, the LPN confirmed both wrong doses were administered and stated the calcium dose was what was available in the medication cart and she did not know what to do to get the correct dosage. The medication administration policy dated 05/01/22 stated medications will be administered as prescribed with the correct dosage.
Incomplete Documentation of Missed Dialysis Notifications
Penalty
Summary
Medical records were not complete and accurate for one resident with ESRD on renal dialysis and heart failure. The resident was admitted on 05/21/25 and had physician orders for dialysis on Tuesday, Thursday, and Saturday with pickup at 5:30 A.M. Review of the record showed an order on 05/27/25 to send the resident to the emergency room for evaluation after staff learned the resident was not picked up for dialysis that morning and may have missed dialysis on 05/24/25 due to transport issues. The progress note documented that the RN notified the NP, who then ordered the resident sent to the hospital for evaluation and treatment because of missed dialysis treatments. The record did not show that the physician was notified when the resident missed dialysis on 05/22/25 or 05/24/25. It also did not document that the physician recommended hospital transfer on those dates or that the resident refused to go to the hospital. During interview, the physician stated he had been notified of the missed dialysis treatments and had suggested hospital evaluation, but the DON and COO verified the medical record was silent for physician notification of the missed dialysis until 05/27/25. The facility policy on Change in Condition Monitoring stated the nurse will record information relative to changes in the resident's medical condition or status.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment for two residents reviewed for homelike environment. Resident #25’s bathroom was observed to smell of urine, with a yellow substance surrounding the base of the toilet, an approximately 8 in by 8 in area of similar yellow substance, and several brown marks throughout the bathroom floor. The resident stated the bathroom floor was dirty and smelled like urine, and said it did not get cleaned very often. A CNA verified the yellow stains, brown marks, and strong urine odor, and stated there had not been a housekeeper assigned to the 100 hall in over a month. Resident #13, who had diagnoses of cerebrovascular disease and obsessive-compulsive disorder, was assessed as cognitively intact and dependent on staff for ambulation. Observation of the resident’s room showed floor tile with multiple pieces missing in front of the resident’s table in the middle of the floor, and additional floor tiles with small missing pieces. An LPN confirmed the missing tile pieces and stated the damaged tile was located in the walkway to the door; the resident used a walker at times to ambulate. The facility’s Homelike Environment policy stated residents are provided with a safe, clean, comfortable, and homelike environment.
Failure to Provide Needed Nail Care
Penalty
Summary
The facility failed to ensure a resident who required assistance with ADLs received adequate nail care. Resident #22 was admitted with diagnoses including acute respiratory failure with hypoxia, COPD, major depressive disorder, dementia, muscle weakness, and need for assistance with personal care. The resident’s MDS showed intact cognition, and the care plan indicated the resident was independent or needed supervision for most ADLs except bathing, with staff to monitor for decline and set up supplies as needed. Task documentation showed the resident required setup, supervision, or limited assistance with personal hygiene tasks and supervision and setup for bathing. Review of shower sheets showed the resident’s nails were last cleaned and clipped on 08/16/25. On 09/08/25, observation revealed several fingernails that were long, extending approximately one inch or more beyond the fingertips, with chipped polish and nails curling and jagged at the edges. The resident stated staff had not helped cut the fingernails in a long time despite requests, that the resident had carpal tunnel syndrome and could not cut them independently, and that the nails were splitting and catching on clothing and bedding. Admissions #162 confirmed the nails were long, jagged, and curling and that the resident needed nail care. The facility policy stated resident nails are expected to be trimmed and kept neat and that nail care will be provided as needed.
Failure to Follow Menu and Provide Substitutions
Penalty
Summary
The facility failed to ensure that menus were followed as planned, which had the potential to affect 59 of the 61 residents who received meals from the kitchen. The menu for breakfast on the specified date included oatmeal or cold cereal, cheesy scrambled eggs, a sausage patty, assorted toast, whole milk or two percent milk, and coffee or tea. However, during an observation, it was noted that the meals served did not align with the menu. Regular diets were served oatmeal, ham, and toast instead of the planned cheesy scrambled eggs and sausage. Mechanical soft diets received oatmeal, mechanical ham, and toast, while pureed diets received oatmeal, pureed scrambled eggs, and pureed sausage, deviating from the planned menu. The staff member interviewed confirmed that the facility was out of sausage and substituted ham for residents on regular and mechanical soft diets without providing a substitution for the cheesy scrambled eggs. Additionally, pureed diets did not receive pureed bread as per the menu spreadsheet. The facility's nutritional services policy stated that food portion sizes should be reviewed by a dietician as needed to ensure nutritional needs are met, but this was not adhered to in this instance. This deficiency was investigated under Complaint Number OH00155177.
Unsanitary Food Storage and Handling
Penalty
Summary
The facility failed to ensure that food items were stored in a sanitary manner, which had the potential to affect 59 of the 61 residents who received meals from the kitchen. During an observation of the kitchen, it was noted that the reach-in refrigerator was at 60 degrees Fahrenheit, which is above the federal standard requirement of storing refrigerated food below 41 degrees Fahrenheit. Inside the refrigerator, there were packages of ham, hamburgers, and hotdogs. Additionally, there was a gray fuzzy substance observed on the line from the ceiling to the steam table and on the ceiling vent above the onions in the dry storage room. Three flies were also seen sitting on the line leading to the steam table. The Dietary Supervisor confirmed the observations, stating that the refrigerator had been broken for approximately one week. The facility's policy on preventing foodborne illness, dated May 1, 2022, was reviewed and it stated that food should be stored, prepared, handled, and served to minimize the risk of foodborne illness. This deficiency was investigated under Complaint Number OH00155177.
Medication Storage Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure medications were stored securely, affecting five residents reviewed for medication storage. For Resident #18, wound cleansing products were found unsupervised in the room, which should not have been there according to the Assistant Director of Nursing. Resident #29 had a bottle of nystatin powder in their room that was intended for another resident, as verified by an LPN. Resident #32 had unsupervised prepared medication left in their room by an LPN, and two tubes of Voltaren ointment, one without a label and the other with a hospital label, were found in the room without orders. Resident #55 had expired nasal spray bottles in their room without orders, and an LPN confirmed they should not have been there. Resident #56's room contained an opened bottle of hydrogen peroxide, a nasal spray bottle, and an opened bottle of acetone fingernail polish remover, all with warning labels, which were verified by an LPN to be inappropriate for the room. Additionally, a treatment cart on the 300 hall was found unlocked and unsupervised, containing medical supplies with warning labels, which was confirmed by an LPN and the Administrator. The facility's policy on medication storage requires all drugs and biologicals to be stored in a safe, secure, and orderly manner, with compartments locked when not in use. The deficiency was identified during a complaint investigation, highlighting the facility's failure to adhere to its own policy, potentially affecting residents identified as cognitively impaired and independently mobile.
Failure to Timely Complete Admission Assessments
Penalty
Summary
The facility failed to ensure timely completion of admission assessments for a resident, identified as Resident #300, in the electronic health record. The resident was admitted with multiple diagnoses, including chronic respiratory failure, COPD, emphysema, congestive heart failure, chronic kidney disease, and hypertension. Despite being cognitively intact and requiring various levels of assistance for daily activities, the resident's admission assessments were not completed until after discharge. These assessments included the Nursing Admission Assessment with Care Plan, Bowel and Bladder Assessment, Braden Scale, dental oral evaluation, pain tool, weekly Head to Toe assessment, and falls assessment. Interviews with staff revealed that the assessments were completed post-discharge, and there was no existing policy regarding the documentation or completion of admission assessments. The Director of Nursing from a sister facility, who was assisting due to an intern DON at the facility, confirmed the delay in documentation. The facility's administrator acknowledged that the assessments were expected to be completed on the day of admission, but this expectation was not met, leading to the deficiency.
Failure in Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during incontinence care for a resident with severe cognitive impairment and multiple medical conditions, including dementia, anxiety, and incontinence. During an observation, a State Tested Nursing Assistant (STNA) was seen providing incontinence care without changing gloves or performing hand hygiene after handling a urine-soaked brief. The STNA used the same gloves to assist the resident and handle various items, including the wheelchair and wipes, without washing hands or changing gloves. Interviews with the STNA and a Corporate Registered Nurse confirmed that the STNA did not follow the facility's policy on hand hygiene and glove use during incontinence care. The facility's policy requires staff to use a clean area of cloth for each area cleaned and to perform hand hygiene after removing gloves. The deficiency was identified during a complaint investigation, highlighting a lapse in infection prevention and control practices.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 695 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Franklin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carlisle Manor Health Care Inc | 2.3 mi | ★★★★★ | 1 | 0 |
| Willow Knoll Post-acute And Senior Living | 3.2 mi | ★★★★★ | 10 | 0 |
| Hillspring Health Care & Rehab | 3.6 mi | ★★★★★ | 0 | 0 |
| Otterbein Middletown | 3.8 mi | ★★★★★ | 13 | 0 |
| Kingston Of Miamisburg | 5.2 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.