Franciscan Village: Unsafe Transfers Harm Residents - IL
That finding, rated by federal inspectors as causing actual harm, was documented during a complaint inspection completed August 21, 2025. It was not the only unsafe transfer inspectors found that week.
The woman, identified in inspection records only as Resident 43, is 97 years old and lives with vascular dementia, poly-osteoarthritis, and generalized muscle weakness. She has a history of falls and a prior fracture of her right hip. On August 19, at 1:25 in the afternoon, two certified nursing assistants, identified as V20 and V21, used a mechanical lift to move her from a reclining wheelchair to her bed.
She was positioned wrong from the start. Her lower buttocks and legs were off the sling entirely, unsupported. V21 acknowledged the sling had been sliding while Resident 43 sat in the reclining chair. Rather than stop and reposition her, V20 placed her arms under the resident's legs and the transfer continued. Resident 43 screamed that her back was hurting throughout.
The inspection report does not describe what happened to Resident 43 after the transfer was complete. It does not say whether she was examined, whether anyone was called, or whether her pain resolved.
The following afternoon, inspectors documented a second unsafe transfer involving a different resident.
Resident 10 is 100 years old. Her diagnoses include spinal stenosis, generalized muscle weakness, lack of coordination, and dementia. Her fall risk score, assessed just one week earlier on August 13, classified her as high risk. The facility's own fall log, covering February through August 2025, shows she had fallen multiple times in that period.
Her care plan listed specific interventions to reduce that risk. One of them was straightforward: place a non-skid mat on her wheelchair seat before transfers.
On August 20, at approximately 12:20 in the afternoon, two nursing assistants, V23 and V29, moved Resident 10 from her bed to her wheelchair using a gait belt. There was no non-skid pad on the wheelchair seat. Resident 10 appeared afraid and hesitant. Her knees were bent and folded during the transfer. She was not fully standing.
The pad that should have been there was not there. The resident the facility had identified as high risk for falls, with a documented history of falling, was transferred into a wheelchair without the one piece of equipment her care plan said she needed.
That same afternoon, at 3:36, the Director of Nursing told inspectors that staff are required to follow all fall prevention interventions for residents identified as high risk, and that assistive devices must be used as recommended.
The gap between that statement and what inspectors had watched happen less than four hours earlier was the center of the federal finding.
A third resident, identified as Resident 52, appears in the inspection record in connection with the fall prevention findings. Her care plan flags her as active and at risk for falls. She overestimates her own abilities following a stroke, has decreased balance and mobility, and has dementia affecting her cognition and thought process. Her care plan calls for two-staff assistance and a gait belt for all transfers. The inspection report does not describe a specific incident involving Resident 52, but her care plan was part of what inspectors reviewed in reaching their conclusions.
Federal inspectors tagged the facility under F0689, the regulation covering accident hazards and supervision, at a level of actual harm.
What the inspection record leaves behind is the image of a woman, 97 years old, in pain, telling the people moving her that her back was hurting, and the transfer continuing anyway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Franciscan Village from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 3, 2026 · Our methodology
FRANCISCAN VILLAGE in LEMONT, IL was cited for violations during a health inspection on August 21, 2025.
That finding, rated by federal inspectors as causing actual harm, was documented during a complaint inspection completed August 21, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.