Franciscan Village
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
Resident R52’s active care plan shows she is at risk/active for falls. Resident R52 has altered safety awareness. Resident R52 overestimates her abilities related to previous CVA (cerebrovascular accident), history of falls, decrease balance/mobility/ADL skills. Decrease cognitive function and decrease thought process due to dementia.
This same care plan shows multiple interventions including two staff assistance with use of gait belt for transfers.
- 3. Face sheet shows that Resident R43 is 97 years-old with multiple medical diagnoses including vascular dementia,
- 4. Face sheet shows Resident R10 is Resident R100 years-old who has multiple medical diagnoses including spinal stenosis,
poly-osteoarthritis, generalized muscle weakness, history of fall, history of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing.
On August 19, 2025, at 1:25 PM, V20 and V21 (Both CNA) transferred Resident R43 from reclining wheelchair to bed via mechanical lift. Resident R43 was positioned in the middle lower half of the sling with the lower part of her buttocks and lower extremities off the sling and not supported. Resident R43 was screaming that her back was hurting. V21 stated the sling was sliding while she was in the reclining chair. V20 placed her arms under Resident R43’s legs during transfer, while Resident R43 was screaming all throughout that her back was hurting.
generalized muscle weakness, lack of coordination, and unspecified dementia.
On August 20, 2025, around 12:20 PM, V23 and V29 (Both CAN) transferred Resident R10 from bed to wheelchair using a gait belt. Resident R10 appeared afraid and hesitant to transfer. Resident R10's knees were bent/folded and was not fully standing. There was no non-skid wheelchair pad on her wheelchair seat. Resident R10 Morse Fall Scale dated 8/13/25 shows, Resident R10 is a high risk for fall.
Facility's fall log from February to August 2025 shows that Resident R10 has had multiple fall incidents. Resident R10's Fall Care Plan shows: Resident R10 is at risk/actual falls related to diagnoses of orthostatic hypotension, history of falls, incontinence, muscle weakness, joint stiffness, and dementia. This same care plan shows interventions which include ensuring non-skid mat on the wheelchair seat.
On August 20, 2025, at 3:36 PM, V2 (Director of Nursing/DON) stated that staff must follow all fall prevention interventions especially for residents who are identified as high-risk for fall. Ensure that staff use assistive device as recommended to prevent fall incidents.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
FRANCISCAN VILLAGE in LEMONT, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LEMONT, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FRANCISCAN VILLAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.