Franklin-Simpson Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for four (4) of 20 sampled Residents (R) (R11, R28, R32, R67) who were unable to freely go outside and one Resident (R32) who had a wander guard in place with no attempts to elope from facility. The findings include:Review of the facility's policy titled, Resident Rights Standard of Practice, dated April of 2024, revealed residents had the right to interact with members of the community and participate in activities both inside and outside of the facility. 1.Review of R11's admission Record revealed the facility admitted the resident on 12/11/2023 with diagnoses which included anxiety disorder and coronary artery disease. Review of R11's Quarterly Minimum Data Set (MDS) assessment dated [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy, it was determined the facility failed to ensure the care plan was followed related to the dietary needs of two (2) of eighteen (18) sampled residents. (Resident #66 and Resident #40) Observation during lunch meal pass on 05/18/2021, Resident #40 and #66 did not have fortified mashed potatoes. Review of care plan interventions for both Resident #40 and #60 interventions directed staff to provide diet as ordered. Additionally, Resident #66 meal ticket required (2) two cartons of milk that were observed to not be on the tray of Resident #66 during meal service. The Findings include: Interview on 05/20/2021 at 4:05 PM, with Administrator, revealed the facility did not have policies or guidelines concerning physician orders, dietary needs or following of care plans for residents. However, the Administrator stated the facility followed the standard of practice for care from Center for Medicare and Medicaid (CMS). Review of provided Clinical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and Code of Federal Regulations (CFR) 483.45(g) review, it was determined the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles for one (1) of the facility's two (2) medication rooms. On [DATE], observation of the medication room on the 200 Hall revealed a Levemir (insulin) pen and Bromfed (antihistamine, cough suppressant, decongestant) liquid were opened. However, the drugs were not dated when opened. Interview with the Administrator revealed the facility did not have a policy for storage and labeling of drugs and biologicals. The findings include: Review of the CFR titled, 483.45(g) Labeling of Drugs and Biologicals and §483.45(h) Storage of Drugs and Biologicals revealed the facility staff should date the label of any multi-use vial when the vial was first accessed and access the vial in a dedicated medication preparation area. If a multi-dose vial had been opened or accessed, the vial should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to provide a well-balanced diet to meet the dietary needs of for two (2) of eighteen (18) sampled residents, Resident # 66 and #40 During lunch meal pass on 05/18/2021, Resident #40 and #66 did not have fortified mashed potatoes per the Meal Ticket, physician order, or care plan. Additionally, Resident #66's Meal Ticket required (2) two cartons of milk to be provided, however, they were not on Resident #66's tray. The Findings include: Interview on 05/20/2021 at 4:05 PM, with the Administrator, revealed the facility did not have for policies or guidelines concerning physician orders, dietary needs or following of care plans for residents. However, the facility does follow the standard of practice for care from Center for Medicare and Medicaid (CMS). Review of the Comprehensive Care Plans Standard of Practice, with revision date of 11/2017, revealed it was the practice of the facility to develop and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and review of facility policy, it was determined the facility failed to ensure food was Stored, prepared, distributed and served in accordance with professional standards for food service safety. Kitchen observations on 02/12/19, revealed open, unsealed foods being stored in the freezer, dirty kitchen equipment and staff sanitation concerns. Review of Census and Condition dated 02/12/19 revealed eighty-two (82) of eighty-six (86) resident receive there meals from the kitchen. The findings include: 1. Review of facility policy titled Food Storage: Cold Foods, revised 4/2018, revealed all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation of the kitchen on 02/12/19 at 09:29 AM, revealed in the three (3) door freezer multiple break apart beef steak slices were laying in the freezer open to air uncovered with no wrapping or container in place and a plastic bag of bread rolls were present with no labeling or dating noted on the bag. 2. Review of facility policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure each resident care plan was reviewed and revised by the interdisciplinary team ongoing with any changes pertinent to the residents' care needs, for five (5) residents (Residents #20, #21, #32, #36, and #71), in the selected sampled of twenty-five (25). Resident #32 had a history of Urinary Tract Infections (UTIs) and had an indwelling urinary catheter. He/she was hospitalized on [DATE] with diagnoses of UTI and Sepsis. However, the comprehensive care plan did not reflect a history of UTIs or Sepsis. Resident #20 had an appointment for cataract surgery on 02/19/18. However, the resident refused to go to the appointment stating I'm not having surgery. The comprehensive care plan was not updated to reflect the resident's preferences related to cataract surgery. Residents #21, #36, and #71 have all had multiple falls in the facility over the course of the last six (6) months. However, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to treat one (1) of twenty-five (25) sampled residents with respect and dignity and care for the resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing the resident's individuality (Resident #36). Resident #36 was resistive to care when staff identified the resident had food on his/her shirt and face after eating his/her meal; however, staff failed to provide a second attempt to clean the resident's face and change shirt for over and hour later and failed to follow facility protocol of having another staff attempt to clean the resident. The findings include: Review of the facility policy titled Resident Rights, not dated, revealed the resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. The resident has the right to be treated with respect and dignity. Record review revealed the facility admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and facility Resident Rights review, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents, the right to have reasonable access to visit his/her son at the facility (Resident #48). The findings include: Review of the facility copy of Resident Rights, not dated, revealed the resident has a right to receive visitors of his or her choosing at the time of his or her choosing. Review of the facility document titled, Resident Right - Inform of Visitation Rights/Equal Visitation Privileges, revealed it is the policy of the facility to inform residents and resident representatives of visitation rights and privileges in such a manner to acknowledge and respect resident rights. Further review of the document revealed the procedures that the facility will meet were as follows: 1. Inform each resident (or resident representative, where appropriate) of his or her visitation rights and related facility policy and procedures, including any clinical or safety restriction or limitation on such rights, consistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of facility policy, and housekeeping inservice training, it was determined that the facility failed to ensure the resident environment was sanitary for one (1) of twenty-five (25) sampled residents (Resident #17). Observation of Resident #17's bathroom on 02/12/19 and on 02/13/19, revealed the commode had dried, crusted fecal matter smeared all over the commode seat and commode bowl in the same areas for the two (2) consecutive days. The findings include: Review of facility policy titled Complete Room Clean Checklist, not dated, revealed the residents' bathrooms were to be cleaned, including the commode, bath tubs, walls and floors. Review of the facility's Housekeeping In-service training for housekeeping employees titled 7-Step Daily Washroom Cleaning, dated 1/1/2000, revealed step five (5) was to clean and sanitized the commode which includes the commode tank, the seat, the bowl and the base. Record review, revealed the facility admitted Resident #17 to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of facility policy, it was determined the facility failed to ensure each resident had a person-centered comprehensive care plan that was developed and/or implemented to meet the residents' preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for one (1) of twenty-five (25) sampled residents (Resident #20). Resident #20 was prescribed Plavix 75 milligrams (mg) (anti-platelet) and Aspirin 325 mg daily. However, there was no documented evidence a care plan was initiated to monitor resident for complications of the medications. In addition, the resident had an uncontrolled nosebleed and was sent to the emergency room on [DATE]; however, the care plan was not revised due to an uncontrolled nose bleed, not reflected on the comprehensive care plan. The findings include: Review of the facility policy titled, Comprehensive Care Plans Standard of Practice, last revised November 2017, revealed it is the practice of the facility to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of facility 24 hour Report, it was determined the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the residents In making appointments, and by arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices for one (1) of twenty-five sampled residents (Resident #20). Resident #20 was seen by an ophthalmologist on 01/22/18 and recommendations were made for the resident to be evaluated by a cataract surgeon. An appointment was scheduled for 02/19/18, however, the resident was a no show, as the resident refused to go to the appointment. He/she was again scheduled to see the ophthalmologist on 08/27/18, but he/she was out of the facility for another doctor's appointment and was not seen by the ophthalmologist. There was no documented evidence the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident, with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible for one (1) of twenty-five sampled residents (Resident #32). Three (3) observations revealed improper positioning of Resident #32's urinary catheter tubing and drainage bag placement. The findings include: A signed statement from the Administrator and the Director of Nursing, dated 02/14/19, revealed the facility does not have a policy for urinary catheter care. However, review of the facility policy titled, Catheter Care, not dated, revealed to secure catheter properly. Coil and secure tubing to the bed. Review of the facility policy titled, Infection Control Tracking and Trending, last revised September, 2013, revealed the purpose of the policy was to prevent the spread of infection and provide appropriate education for staff and residents concerning infection control. Record review revealed the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to apply oxygen (O2) therapy according to the Physician's Order for one (1) of twenty-five (25) sampled residents (Resident #7). Observation on 02/12/19 revealed staff failed to ensure Resident #7 received O2 at three (3) liters per minute (LPM) per the Physician's Order. The findings include: Review of the facility's policy titled, Oxygen Administration and Maintenance, not dated, revealed Oxygen will be administered in accordance with physician's orders. The nurse will be responsible for ensuring oxygen is applied per physician's orders. Record review revealed the facility admitted Resident #7 on 03/03/18 with diagnoses which included Chronic Obstructive Pulmonary Disease, Chronic Bronchitis, and Dyspnea. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/16/18 , revealed the facility assessed Resident #7's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.