Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legacy Nursing And Rehabilitation Of Franklin during CMS and state inspections, most recent first.
A cognitively intact resident who required assistance with bathing was showered unclothed in a shared shower room while multiple other residents were present, and additional residents were brought into the room during the process. The resident reported feeling uncomfortable with showering in the presence of others. Staff, including CNAs and nursing leadership (ADON and DON), acknowledged that the number of residents in the shower room at the same time did not allow for adequate privacy, contrary to the facility’s stated resident rights and dignity policy.
Two residents’ rights to a safe, clean, and comfortable environment were not maintained when one resident with multiple pressure ulcers and incontinence was repeatedly observed lying directly on a pressure reduction mattress without a cover sheet, despite her requests for one and manufacturer guidelines allowing a thin sheet, while facility leadership acknowledged the practice was not to offer a choice for a cover. Another incontinent resident reported and was observed to have wet and soiled bed linens that remained unchanged into the next day, with visible dried stains, despite expectations that CNAs check rooms every two hours and change linens when soiled or upon resident request.
A CNA was hired without the required registry verification being completed prior to employment. Review of records and staff interviews confirmed that the registry check was performed after the CNA was already hired, with no documentation showing it was done beforehand.
A resident with a history of multiple falls and complex psychiatric and neurological diagnoses did not receive timely PT, OT, and ST evaluations as ordered by a physician. Although therapy services were ordered, the evaluations were not completed until several weeks later, with staff confirming the delay and lack of documentation for timely completion.
A resident requiring moderate assistance with ADLs did not receive adequate personal hygiene care, including hair washing and shaving. Observations noted white flakes in the resident's hair and unshaved facial hair. Interviews confirmed the lack of assistance, and staff acknowledged the deficiency.
The facility failed to allow residents identified as safe smokers to keep their smoking supplies and smoke at their leisure, contrary to its policy. Residents expressed dissatisfaction with the restricted smoking times and the removal of their smoking materials, which were locked away and only distributed at specific times. This change was implemented without proper notification or response to residents' requests for a meeting with the administrator.
The facility did not document or respond to concerns raised during resident council meetings for three months. Residents reported that their grievances were not addressed, and staff confirmed the absence of documented responses. The administrator was unaware of a request to meet regarding smoking times.
A facility failed to provide a resident with prescribed eye drops due to a backorder and did not notify the physician for an alternative. Additionally, discrepancies were found in the controlled medication counts for several residents, with mismatches between medication cards and administration records confirmed by an LPN and the DON.
A facility failed to maintain a medication error rate below 5%, resulting in a 12.9% error rate. An LPN improperly administered medications by opening capsules of Tolterodine and Fetzima, which should be taken whole, and failed to administer prescribed eye drops due to a backorder. The pharmacist confirmed the error, and the DON acknowledged the rate exceeded the threshold.
A resident with a diagnosis of otitis media reported ear pain and drainage to an LPN, but the physician was not notified. The resident, who was cognitively intact, confirmed that no action was taken, and he had not been seen by a physician. The LPN admitted she should have informed the doctor, and the DON agreed with this assessment.
A resident with moderate cognitive impairment was involved in two incidents of physical abuse by other residents. In one instance, a resident was hit in the head, and in another, the resident was pushed against a wall, resulting in a swollen and bleeding lip. Staff confirmed hearing the resident scream for help and observed the injuries. The facility's failure to prevent these incidents highlights a deficiency in abuse prevention measures.
A facility failed to report incidents of resident-to-resident physical abuse to the Statewide Incident Management System (SIMS) as required. A resident with moderate cognitive impairment was involved in two separate incidents where they were physically abused by other residents, resulting in a swollen and bleeding lip. Staff members confirmed the incidents and the failure to report them, and the facility administrator acknowledged the oversight.
A resident was administered oxygen at 3 lpm instead of the prescribed 2 lpm via nasal cannula. This discrepancy was observed over three days and confirmed by an LPN and the DON, who acknowledged the error in following the physician's orders.
A facility failed to assess and manage a resident's pain according to its Pain Management Policy. The resident, admitted with otitis media, received Tylenol for high pain ratings without documented reasons or characteristics of the pain. Despite reporting ear pain and drainage, the resident was not assessed by a doctor, and no treatments were communicated. An LPN confirmed the resident's complaints, but the DON could not explain the lack of assessment or adherence to policy.
The facility failed to post accurate and current staffing information for four consecutive days. Observations revealed that the Staffing Disclosure Logs were missing the facility name and census information. The DON confirmed that these details should have been included on the logs.
A resident with chronic kidney disease and paralysis left the facility against medical advice and was discharged to an unsuitable location. The facility failed to document informing the resident of the risks, presenting alternative options, or understanding the resident's choice. Staff interviews confirmed the location was not equipped to meet the resident's needs, and the facility lacked documentation to dispute these findings.
A resident with Alzheimer's and malnutrition experienced a significant decline in oral intake over several days, but the LTC facility staff failed to notify the resident's physician and responsible party. The resident, who was nonverbal and dependent on staff for eating, was eventually hospitalized in critical condition with severe dehydration and other complications. Interviews confirmed the lack of timely communication, leading to an Immediate Jeopardy situation.
A resident with Alzheimer's and other health issues experienced severe dehydration and hospitalization due to the facility's failure to implement a dietitian's recommendation for a nutritional supplement. Despite significant weight loss and poor food intake, the staff did not notify the physician or adjust the resident's dietary needs, resulting in critical health conditions.
A facility failed to communicate a resident's change in condition to the physician and responsible party, resulting in severe dehydration and hospitalization. The resident, who was nonverbal, experienced a significant decline in oral intake, which was not reported by the nursing staff. Additionally, a dietitian's recommendation for a nutritional supplement was not implemented or communicated to the physician. This neglect led to the resident's critical condition, including severe dehydration, hypernatremia, acute renal failure, and metabolic encephalopathy.
A facility failed to securely store medications at a nursing station, leaving a medication card with Ropinrole tablets and a bottle of Guaifenesin unattended on a counter. An LPN placed the medications there, intending for a CNA to supervise them, as the responsible nurse was unavailable. The facility's policy requires medications to be stored securely and accessed only by authorized personnel.
A facility failed to ensure a registered nurse assessed a resident's diabetic ulcer before delegating care to an LPN, and did not complete required weekly wound assessments. The resident's records lacked evidence of an RN's initial assessment and weekly evaluations, as confirmed by the DON and involved LPNs.
A facility failed to ensure a registered nurse assessed a resident's Stage III sacral pressure ulcer for stability before delegating care to an LPN. The resident's ulcer was assessed by an LPN upon admission and readmission without RN documentation. Additionally, the facility did not complete required weekly assessments for the ulcer, as confirmed by the DON and LPNs.
A facility failed to complete ordered laboratory tests for a resident with a Stage IV pressure ulcer. The resident's physician had ordered monthly tests, including a CMP, CBC, and Prealbumin level, to monitor their condition. However, there was no evidence that the Prealbumin test was completed in one month, and none of the tests were completed the following month. The DON confirmed the oversight during an interview.
Failure to Ensure Resident Privacy and Dignity During Group Showering
Penalty
Summary
The facility failed to protect a cognitively intact resident’s right to privacy and dignity during bathing. The facility’s Resident Rights and Quality of Life Policy stated that all residents had the right to a dignified existence and were to be treated with consideration of their dignity, including privacy in treatment and care for personal needs. Resident #49’s Minimum Data Set, with an Assessment Reference Date of 11/13/2025, showed a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact and required assistance for showering and bathing. On 01/07/2026 at 9:35 AM, surveyor observation revealed that six residents (Residents #16, #29, #49, #106, #108, and #113) were all in Shower Room C at the same time, and Resident #49 was unclothed in the shower being assisted by S7 Certified Nursing Assistant. At 9:36 AM, the door to the shower room opened and S6 Certified Nursing Assistant brought Resident #22 into the same shower room. During an interview at 9:40 AM, Resident #49 stated she was not comfortable showering in Shower Room C with the other residents present. In subsequent interviews, S6 Certified Nursing Assistant, the Assistant Director of Nursing, and the Director of Nursing all acknowledged that the number of residents in Shower Room C at the same time did not allow for resident privacy and that Resident #49 was out of her comfort zone with the number of residents present while she was showering.
Failure to Provide Clean Linens and Honor Resident Choice for Mattress Cover
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to a safe, clean, comfortable, and homelike environment, specifically regarding bed linens and use of pressure reduction mattresses. One resident with Stage 3 and Stage 4 sacral pressure ulcers and a Stage 2 buttocks pressure ulcer had a physician’s order for a pressure reduction mattress and was always incontinent of bowel and bladder. Manufacturer guidelines for the pressure mattress allowed for a thin cotton sheet over the top cover. Multiple observations on separate days showed this resident lying with skin in direct contact with the mattress surface and no sheet in place. The resident reported that she had asked staff for a cover sheet, but her request was not honored. The CNA Supervisor stated that while the facility’s practice was not to use a cover sheet on pressure reduction mattresses, a sheet should be provided if requested as part of resident rights. The DON confirmed that the facility’s practice was not to use a cover sheet and that residents were not given a choice, although they should have been. The deficiency also includes failure to maintain clean, dry bed linens for another resident who was always incontinent of bowel and bladder. This resident reported that her bed linens were wet and soiled, which was confirmed by observation. On the following day, the resident stated that her linens were still soiled and had not been changed, and observation revealed dried brown and yellow stains on the bed linens. The CNA Supervisor indicated CNAs were expected to check resident rooms every two hours for needs or assistance and that CNAs were responsible for checking and changing soiled bed linens. A CNA stated that linens should be changed when requested by a resident or when wet or soiled. Both the DON and CNA Supervisor acknowledged that this resident’s linens should not have remained soiled and should have been changed in a timely manner.
Failure to Verify CNA Registry Status Prior to Hire
Penalty
Summary
The facility failed to obtain Certified Nursing Assistant (CNA) registry verification prior to hiring one CNA. Review of the personnel record for this CNA showed a hire date of 07/10/2024, but the registry verification was dated 03/20/2025, indicating it was completed after the individual was already hired. There was no documented evidence provided by the facility to show that the required registry check was performed before employment. Interviews with the Human Resource designee and the Administrator confirmed that the CNA registry check was not obtained prior to hire as required.
Delay in Completion of Ordered Therapy Evaluations for Resident with Multiple Falls
Penalty
Summary
The facility failed to complete timely physical therapy, occupational therapy, and speech therapy evaluations as ordered for a resident with a history of multiple falls. The resident, who was admitted with diagnoses including impulse disorder, psychosis, schizoaffective disorder, major depressive disorder, pseudobulbar affect, and extrapyramidal movement disorder, experienced numerous falls over a two-month period. Despite a physician's order dated 01/07/2025 for therapy evaluations and treatment, these evaluations were not completed until 01/27/2025. Review of the resident's medical record and therapy documentation confirmed that there was no evidence the required therapy evaluations were conducted prior to 01/27/2025, even though the order was placed on 01/07/2025. Interviews with facility staff, including the Therapy Director and DON, confirmed the delay and attributed it in part to staffing issues. The administrator also confirmed the absence of documentation showing timely completion of the therapy evaluations as ordered.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident who required moderate assistance with showering, bathing, and personal hygiene. The resident's care plan indicated a need for assistance with all ADLs, including bathing and personal hygiene. However, documentation revealed that the resident received infrequent bed baths and showers, with no evidence of hair washing. Observations confirmed the presence of white flakes in the resident's hair and on their shirt, and facial hair that was not shaved as required. Interviews with the resident and staff confirmed the lack of assistance with hair washing and shaving. The resident expressed a preference for bed baths but also a desire for hair washing and shaving, which were not provided. Staff interviews revealed that the Certified Nursing Assistant (CNA) had not attempted to wash the resident's hair or shave them. The Infection Preventionist and Director of Nursing confirmed the presence of flakes in the resident's hair and acknowledged the need for dandruff shampoo and assistance with shaving.
Facility Restricts Safe Smokers' Rights
Penalty
Summary
The facility failed to honor the rights of residents identified as safe smokers by not allowing them to keep their smoking supplies and smoke at their leisure. The facility's policy stated that residents with independent smoking privileges were permitted to keep smoking materials in their possession. However, observations and interviews revealed that residents were required to wait for staff to provide their smoking materials at designated times, which restricted their ability to smoke freely. This change in procedure was implemented without proper notification or documentation of a response to residents' requests for a meeting with the administrator to discuss the changes. Residents expressed dissatisfaction with the new smoking procedure, feeling that it treated them like children and restricted their autonomy. One resident, who was identified as a safe smoker with no restrictions, reported increased anxiety due to the limited smoking times and the removal of personal smoking supplies. The facility's actions were inconsistent with the residents' rights to self-determination and communication, as outlined in their care plans and the facility's smoking policy. Interviews with staff confirmed the removal of smoking materials and the restriction of smoking times, which contradicted the facility's stated policies.
Failure to Document and Respond to Resident Council Concerns
Penalty
Summary
The facility failed to respond and maintain documented responses to complaints voiced during resident council meetings. The facility's grievance policy requires that resident council meeting minutes be reviewed by administration, and any grievances should be promptly addressed. However, interviews with residents and staff revealed that the facility did not follow up on concerns raised during the resident council meetings for three consecutive months. Residents expressed that their concerns were not addressed, and there was no documented evidence of responses to their grievances. The resident council meeting minutes from October, November, and December 2024 showed no documented responses to the issues discussed, including a request to meet with the administrator regarding smoking times. Interviews with the Assistant Activity Director and Social Worker confirmed the absence of documented responses. The administrator admitted that he was not informed of the resident council's request to meet with him and acknowledged the lack of documented evidence of the facility's response to the council's concerns.
Medication Availability and Record Discrepancies
Penalty
Summary
The facility failed to ensure the availability of medications for a resident and maintain accurate records of controlled substances. Resident #16 did not receive her prescribed Systane Balance Ophthalmic Solution due to the medication being on backorder. The LPN confirmed the unavailability of the medication and acknowledged that the resident's physician should have been informed to consider an alternative medication. Additionally, discrepancies were found in the controlled medication counts for several residents. The medication cards and controlled medication administration records did not match for residents receiving medications such as Alprazolam, Tramadol, Clonazepam, Oxycodone/APAP, and Lorazepam. The LPN and the DON confirmed that the counts should have been consistent between the medication cards and the administration records.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 12.9% error rate during medication administration for a resident. The deficiency was identified through record reviews, observations, and interviews. Specifically, an LPN administered medications incorrectly by opening capsules of Tolterodine and Fetzima and placing the contents on pudding, despite these medications being required to be taken whole. Additionally, the resident did not receive their prescribed Systane Balance Ophthalmic Solution due to it being on backorder, and the physician was not notified of this issue. The pharmacist confirmed that the medications should not have been opened, and the Director of Nursing acknowledged that the error rate exceeded the acceptable threshold. The Assistant Director of Nursing noted that the resident's doctor should have been informed about the unavailability of the eye drops. These actions and inactions contributed to the facility's failure to adhere to proper medication administration protocols, leading to the identified deficiency.
Failure to Notify Physician of Resident's Ear Pain and Drainage
Penalty
Summary
The facility failed to ensure a resident's physician was immediately notified of a resident's ear pain and drainage. Resident #43, who was admitted with a diagnosis of otitis media in the right ear, reported ear pain and drainage to a nurse the previous week. Despite being cognitively intact, as indicated by a Brief Interview Mental Status Score of 15, Resident #43 stated that no action had been taken regarding his complaints. The resident confirmed in interviews that he had not been seen by a physician or received any information about his ear condition. A Licensed Practical Nurse (LPN) acknowledged that the resident had complained of ear pain and drainage over the weekend and admitted that she should have notified the doctor but did not. The Director of Nursing confirmed that the LPN should have notified the doctor if she felt it was necessary.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from resident-to-resident physical abuse. The deficiency involved Resident #112, who was subjected to physical abuse on two separate occasions. The first incident occurred when Resident #24 hit Resident #112 in the back of the head at the dining room doorway. When questioned, Resident #24 expressed a belief that he could hit whoever he wanted. The second incident involved a physical altercation initiated by Resident #174, during which Resident #112 was pushed against a wall and sustained a swollen and bleeding lip. Interviews with staff members, including a CNA and an LPN, confirmed that they heard Resident #112 scream for help during the second incident and observed the physical altercation. The CNA intervened to separate the residents, and both staff members noted the injury to Resident #112's lip. The Director of Nursing and the Administrator were aware of these incidents, which were classified as resident-to-resident abuse, indicating a failure in the facility's abuse prevention measures.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report allegations of physical abuse involving a resident to the Statewide Incident Management System (SIMS) as required. The facility's policy mandates that any alleged abuse must be reported immediately, or within two hours if it involves abuse or results in serious bodily injury, and within 24 hours if it does not involve abuse or serious injury. However, the incidents involving Resident #112 were not reported to SIMS. Resident #112, who has moderate cognitive impairment, was involved in two separate incidents of physical abuse by other residents. In the first incident, Resident #24 hit Resident #112 in the back of the head. In the second incident, Resident #174 pushed Resident #112 against a wall, resulting in a swollen and bleeding lip. Interviews with staff members confirmed the incidents and the failure to report them. S7CNA and S6LPN both witnessed the altercation between Resident #112 and Resident #174, noting that Resident #112 was screaming for help and had blood on her lips. The facility administrator acknowledged that these incidents constituted resident-to-resident abuse and admitted that they were not reported to SIMS as required by the facility's policy and state guidelines.
Oxygen Administration Not in Accordance with Physician's Orders
Penalty
Summary
The facility failed to administer oxygen to a resident according to the physician's orders. The physician's orders for the resident specified oxygen administration at 2 liters per minute (lpm) via nasal cannula. However, observations on three consecutive days revealed that the resident received oxygen at 3 lpm instead. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) and acknowledged by the Director of Nursing (DON), both of whom confirmed that the oxygen should have been administered at the prescribed rate of 2 lpm.
Failure to Assess and Manage Resident's Pain
Penalty
Summary
The facility failed to fully assess and manage the pain of Resident #43, who was admitted with a diagnosis of otitis media in the right ear. The facility's Pain Management Policy and Procedure required documentation of the reason for pain, characteristics of pain, and the effectiveness of pain management. However, the records for Resident #43 showed multiple instances where Tylenol was administered for high pain ratings without documented evidence of the reason or characteristics of the pain. Specifically, on several occasions in January 2025, Tylenol was given for pain ratings of 6 and 8, but the facility did not provide documentation for the reason or characteristics of the pain, except for one instance where right side pain/earache was noted. Interviews with Resident #43 revealed that he reported right ear pain and drainage to the nursing staff, but no further assessment or treatment was conducted. The resident expressed that despite his complaints, no doctor had assessed him, and no treatments were communicated to him. An LPN confirmed that the resident had complained of ear pain and drainage, and she noted minimal drainage in the resident's right ear. The Director of Nursing could not explain why the staff failed to assess the resident's ear pain and drainage or why the facility's pain management policy and procedures were not followed.
Inaccurate Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the posted staffing information was accurate and current for four consecutive days. Observations on January 5, 2025, revealed that the Staffing Disclosure Logs for January 4, 5, and 6, 2025, were missing the facility name and the facility census. A subsequent observation on January 7, 2025, showed that the Staffing Disclosure Log for that day also lacked the facility name and census information. During an interview on January 7, 2025, the Director of Nursing confirmed that the facility's name and daily census should have been documented on the posted Daily Staffing Disclosure Logs for the dates in question.
Failure in Discharge Planning for Resident Leaving AMA
Penalty
Summary
The facility failed to implement an effective discharge planning process for a resident who left against medical advice. The resident, who had chronic kidney disease, paralysis, and required dialysis, was discharged to an apartment that was not equipped to meet his needs. The facility's documentation did not show that the resident was informed of the risks of being discharged to an unsuitable location, nor did it show that alternative, more suitable options were presented and discussed with the resident. Despite the resident's decision to leave against medical advice, the facility did not document attempts to understand why the resident chose the location or if other options were refused. Interviews with facility staff, including social services, nursing, and administration, revealed that the resident required significant assistance with activities of daily living and had urgent medical needs due to dialysis. The staff acknowledged that the location to which the resident was discharged was not equipped to meet these needs. The facility did not provide any documentation to dispute these findings, and the administrator admitted that the required documentation related to the resident's discharge was not completed.
Failure to Notify Physician and Family of Resident's Decline
Penalty
Summary
The facility failed to ensure timely communication of a significant change in condition to a resident's physician and responsible party, resulting in an Immediate Jeopardy situation. A resident, who was nonverbal and dependent on staff for eating, experienced a decline in oral intake over several days. Despite the resident's inability to adequately eat or drink, the nursing staff did not notify the resident's physician or responsible party on multiple occasions, specifically on July 12 and July 13, 2024. The resident had a history of Alzheimer's Disease, malnutrition, and muscle wasting, and was noted to have a significant weight loss over three months. On July 12, 2024, the resident was observed with possible dental issues and was unable to chew food. The following day, the resident was found holding food in their mouth with fluids dripping out, yet there was no documented evidence of notification to the responsible party. The situation escalated on July 14, 2024, when the resident was found lethargic with involuntary jerking movements and was subsequently sent to the hospital. Hospital records indicated the resident was in critical condition, diagnosed with severe dehydration, severe hypernatremia, moderate acute renal failure, and metabolic encephalopathy. Interviews with the nursing staff and the resident's responsible party confirmed the lack of timely notification. The responsible party stated they would have intervened had they been informed earlier. The facility's failure to communicate these significant changes in the resident's condition led to the Immediate Jeopardy situation.
Failure to Implement Nutritional Recommendations Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to maintain acceptable nutritional and electrolyte balance parameters for a resident, leading to an Immediate Jeopardy situation. The staff did not follow up on or implement a dietitian's recommendation for a nutritional supplement, Twocal, for a resident who had experienced significant weight loss. The resident, who had Alzheimer's Disease, Type 2 Diabetes, malnutrition, and muscle wasting, was dependent on staff for eating and was rarely or never understood. Despite a dietitian's recommendation for Twocal due to a 10.7% weight loss over three months, there was no documented evidence that the physician was notified or that the recommendation was implemented. The resident's weight records showed fluctuations, with a significant weight loss noted between January and April, and no weights documented after early July. The resident's care plan indicated a need for staff assistance with feeding due to dementia, yet the staff failed to ensure adequate food and fluid intake. On specific days in July, the resident's food intake was minimal, and staff documented difficulties in getting the resident to eat. Despite these challenges, the staff did not notify the physician or responsible party about the resident's poor intake. The resident was eventually found lethargic with involuntary jerky movements and was hospitalized in critical condition with severe dehydration, hypernatremia, acute renal failure, and metabolic encephalopathy. The physician confirmed not being informed of the dietitian's recommendation and noted the severe dehydration indicated poor oral intake for at least a week. The prior DON acknowledged that a significant change in the resident's eating habits should have prompted immediate notification to the physician.
Failure to Communicate Change in Condition and Implement Nutritional Recommendations
Penalty
Summary
The facility failed to administer care effectively and efficiently, resulting in a significant deficiency. The staff did not communicate a resident's change in condition to the physician and responsible party in a timely manner. This failure involved a resident who was nonverbal and unable to communicate his needs. The nursing staff did not notify the physician or the resident's responsible party about the resident's poor oral intake over two days, which was a significant change given the resident's history of a good appetite and need for double portions. This lack of communication contributed to the resident's severe dehydration and subsequent hospitalization. Additionally, the facility did not follow up on or implement a dietitian's recommendation for the resident to receive a nutritional supplement. The Quality Improvement Nurse was unaware of the dietitian's recommendation and failed to notify the physician. The resident's physician confirmed that the resident's severe dehydration indicated poor oral intake for at least a week, suggesting a prolonged period of neglect. The resident experienced a significant weight loss and was hospitalized in critical condition with severe dehydration, hypernatremia, acute renal failure, and metabolic encephalopathy.
Medication Storage Deficiency at Nursing Station
Penalty
Summary
The facility failed to ensure medications were stored securely at Nursing Station x, as observed during a survey. A medication card containing 15 Ropinrole tablets and a medication bottle with 240 ml of Guaifenesin, both prescribed for a resident, were left unattended on the counter. These medications were filled by the pharmacy on the same day they were observed unsecured. The facility's Medication Storage policy mandates that medications be stored safely and securely, accessible only to those authorized to administer them. The incident was further clarified through interviews. The Minimum Data Set Nurse reviewed camera footage and confirmed that an LPN placed the medications on the counter and left them unattended. The LPN admitted to receiving the medications from the pharmacy and leaving them on the counter under the supervision of a CNA, as the responsible nurse was unavailable. The LPN acknowledged that the medications should have been secured in the locked medication room instead of being left with an unauthorized CNA.
Failure to Ensure RN Assessment and Weekly Wound Evaluations
Penalty
Summary
The facility failed to ensure that a registered nurse assessed a resident's left heel diabetic ulcer to determine its stability and predictability before delegating care to a licensed practical nurse (LPN). This deficiency was identified for one resident who had a diabetic foot ulcer. The resident's records showed that the ulcer was assessed and measured by an LPN without prior assessment by a registered nurse, both upon admission and readmission. The Director of Nursing confirmed the lack of documented evidence of a registered nurse's initial assessment, which is required to delegate wound care to an LPN. Additionally, the facility did not complete weekly assessments of the resident's left heel diabetic ulcer as required by their Skin/Wound Documentation Policy and Procedure. The resident's records lacked documented evidence of weekly wound assessments for specific weeks following both admission and readmission. Interviews with the Director of Nursing and the involved LPNs confirmed that weekly assessments should have been conducted and documented, but were not, during the specified time frames.
Failure to Ensure RN Assessment and Weekly Monitoring of Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a registered nurse assessed a resident's Stage III sacral pressure ulcer to determine its stability and predictability before delegating care to a licensed practical nurse. This deficiency was identified for one resident who was admitted and later readmitted to the facility with a Stage III pressure ulcer. The resident's pressure ulcer was initially assessed and measured by a licensed practical nurse upon both admission and readmission, without documented evidence of a registered nurse's assessment. The Director of Nursing confirmed the absence of documentation showing that a registered nurse had deemed the wound stable and predictable prior to delegation. Additionally, the facility did not complete weekly assessments for the resident's Stage III sacral pressure ulcer as required by their Skin/Wound Documentation Policy and Procedure. There was no documented evidence of weekly assessments for specific weeks following the resident's admission and readmission. Interviews with the Director of Nursing and licensed practical nurses confirmed that weekly wound assessments were expected but not documented for the specified time frames.
Failure to Complete Ordered Laboratory Tests for Resident
Penalty
Summary
The facility failed to ensure that a resident's laboratory tests were completed as ordered by the physician. Resident #3, who was admitted with a Stage IV pressure ulcer, had physician orders for monthly laboratory tests, including a Complete Metabolic Panel (CMP), Complete Blood Count (CBC), and Prealbumin level, to monitor their condition until the ulcer healed. However, there was no documented evidence that the Prealbumin test was completed in May 2024, nor were the CMP, CBC, and Prealbumin tests completed in June 2024 as ordered. The Director of Nursing confirmed that the laboratory tests were not completed as required, indicating a lapse in following physician orders for Resident #3's care. This deficiency was identified during a review of the resident's records and an interview with the Director of Nursing.
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 28 citations issued within 25 miles in the last 12 months — 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) |
|---|---|---|---|---|
| Patterson Healthcare Center | 14.5 mi | — | 10 | 0 |
| Maison Teche Nursing Center | 16.2 mi | — | 9 | 0 |
| Consolata Rehab And Wellness Center On The Teche | 20.9 mi | — | 5 | 0 |
| New Iberia Manor South | 21.5 mi | — | 1 | 0 |
| Legacy Nursing And Rehabilitation Of Morgan City | 21.5 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Legacy Nursing And Rehabilitation Of Franklin.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.