Franciscan Health Care Center

Based on observation, interview, record review, and review of facility documentation, the facility failed to ensure necessary care and services (i.e. nail care) were provided for residents unable to carry out their own activities of daily living (ADLs) for 3 of 35 sampled residents, (Resident (R)81, 91, and 100). The findings include:During interview on 09/20/2025 at 1:44 PM, the Division [NAME] President (DVP) stated the facility did not have a policy related to trimming or cleaning residents' nails. The DVP stated the Certified Resident Care Associate's (CRCA) checklist noted the CRCAs were responsible for grooming, which included trimming/cleaning residents' nails who did not have a diagnosis of diabetes.Review of the facility document titled, Job Descriptions, for a Certified Resident Care Associate, revealed staff were to, Assist residents with nail care (i.e., clipping, trimming, and cleaning the finger/toenails. (NOTE: Does not include diabetic residents).1. Record review revealed the Resident Face Sheet noted the facility admitted R!00 on 09/11/2025, with diagnoses that…

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, facility document and policy review, the facility failed to ensure a medication error rate of less than 5 percent (%) or less, with 6 errors out of 30 opportunities, which yielded a medication error rate of 20% involving 4 of 4 residents observed for medication administration out of the total sample of 35 (Residents (R)21, 2, 13, and 15). The findings include:Review of the facility policy titled, Medication Administration-General Guidelines, revised 11/2018, revealed the FIVE RIGHTS for medication administration included the right resident, right drug, right dose, right route, and right time, and those rights were to be applied for each medication being administered. Per review, a triple check of the Five Rights was recommended at three steps in the process of preparation of a medication for administration. Continued review revealed the three steps included checking when the medication was selected; when the dose was removed from the container; and finally just after the dose was prepared and the medication was put away. Review of 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 facility policy review, the facility failed to assess residents for self-administering medications for 1 of 2 residents sampled for accidents, (Resident (R)101), out of the total sample of 35. The findings include:Review of the facility policy titled, Guidelines for Self-Administration of Medications, dated 05/22/2018, revealed in the section designated Procedure, residents requesting to self-medicate or who had self-medication as a part of their plan of care were to be assessed using the observation Self Administration of Medication within the electronic health record (EHR). Per policy review, the results of the assessment were to be presented to the physician for evaluation and an order obtained for self-medication. Continued review revealed the order was to include the type of medication(s) the resident was able to self-medicate. Policy review revealed the resident and/or family/responsible party were to be informed of the results of the assessment and whether the resident had been determined to safely self-administer…

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 facility policy review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) form 2 of 3 residents reviewed for beneficiary notification out of the total sample of 35, (Resident (R)6 and 108). Specifically, the facility failed to issue a SNF ABN to Resident #6 and Resident #108 when the facility notified the residents that they were discharged from Medicare Part A services, even though their benefit days had not been exhausted.The findings include:Review of the Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (2024), revealed the SNF ABN Form provided information to residents so they could decide whether or not to get the care that might not be paid for by Medicare and assume financial responsibility for that care. Per review, SNFs must use the SNF ABN Form when applicable for SNF Prospective Payment System (PPS) services (Medicare Part A). Further…

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 facility policy review, the facility failed to timely report an allegation of abuse for 1 of 1 resident reviewed for abuse, out of the total sample of 35, (R103).The findings include:Review of the facility policy titled, Abuse, Neglect and Exploitation Procedural Guidelines, revised 12/16/2024, revealed under the section titled Procedure the reporting/response noted any staff member, resident, visitor, or resident representative might report known or suspected abuse, exploitation, neglect, or misappropriation to local or state agencies. Per policy review, all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were to be reported immediately; however, not later than two hours after the allegation was made if the events that caused the allegation involved abuse or result in serious bodily injury. Continued review revealed if the allegation did not involve abuse or serious…

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, record review, interview, and facility policy review, the facility failed to obtain an order for the use of oxygen for 1 of 4 residents reviewed for respiratory care out of the total sample of 35 (Resident (R)17).The findings include:Review of the facility policy titled, Administration of Oxygen, reviewed 12/13/2024, revealed a section titled , SOP Details that noted staff were to verify the physician's order for the procedure. Further review revealed in cases of emergency oxygen might be administered as a nursing intervention until a physician order may be obtained.Review of the Resident Face Sheet for R17 revealed the facility admitted the resident on 08/21/2025, diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute and chronic respiratory failure with hypoxia (low levels of oxygen in body tissue), and hypercapnia (elevated levels of carbon dioxide in the blood).Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/28/2025, revealed the facility assessed R17 as having a…

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, the facility failed to ensure a resident was assessed for bed rail use and consent obtained for the use of the bed rails for 1 of 2 residents reviewed for accidents, out of the total sample of 35 residents (Resident (R)101). The findings include:Review of the facility policy titled, Guidelines for the Use of Bed Rails, dated 10/09/2017, revealed prior to the installation of bed rails, the facility was to attempt to use alternatives. Per review, if the alternatives attempted were not adequate to meet the resident's needs, the resident was assessed for the use of bed rails. Continued policy review revealed the bed rail assessment was to include review of risks including entrapment; and informed consent for the rails to be obtained from the resident or if applicable, the resident's representative. Further review revealed the facility must ensure the bed was appropriate for the resident and the bed rails were properly installed and maintained. In addition, review of the policy also revealed the use of bed rails…

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, the facility failed to ensure medication carts were clean, organized, and medications that were opened had an opened date for 5 of 5 medication carts observed (the medication carts involved were: Downtown, Berry, Bell 1, Bell 2, and TCU 1) Further observation revealed 10 total medication carts located within the facility. The findings include:Review of the facility policy titled, Medication Storage in the Facility-Storage of Medications, revised 11/2018, revealed medication storage areas were to be kept clean, well-lit, and free of clutter and extreme temperatures and humidity. Per policy review, certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerine tablets, blood sugar testing solutions and strips, once opened, required an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. Continued review revealed drugs dispensed in the manufacturer's original container were to carry the manufacturer's…

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, the facility failed to ensure staff cleaned and disinfected glucometers (device used to monitor blood sugar levels) after use for 1 of 2 residents observed for glucometer checks, out of the total sample of 35.The findings include:Review of the facility policy titled, Glucometer Cleaning and Control Test Guidelines, dated 05/11/2016, revealed if glucometers were used from one resident to another, they should be cleaned and disinfected after each use. Further review revealed to see the manufacture [sic] guidelines for cleaning and disinfecting.Review of the manufacturer's guidelines for the facility's, Assure Prism multi Blood Glucose Monitoring System revealed the blood glucose monitor/meter was only to be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures were followed. Per review of the guidelines, the meter was to be cleaned and disinfected after use on each resident. Continued review revealed Super Sani-Cloth Germicidal Disposable Wipes had been…

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 and record review, and review of the facility's policy, the facility failed to ensure residents received care to prevent pressure ulcers from developing for one of three residents reviewed for pressure ulcers (Resident (R) 8). The findings include: Review of facility policy, Guidelines for Weekly Skin Observation, reviewed 12/17/2024 revealed a purpose statement, to monitor the effectiveness of intervention for pressure reduction, identify areas of skin impairment in the early development stage and implement other preventative and/or treatment measures as indicated. Further review revealed item #6 stated, In addition to the Weekly Observation by the licensed nurse, the nursing assistant shall observe the skin for areas of impairment with bathing and daily dressing and pericare and notify the nurse if an area is identified. Review of facility policy, Turning and Repositioning, reviewed 12/16/2024 revealed an overview statement indicating, those requiring assistance to reposition while in bed…

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 record review, interview, and document review, the facility failed to accurately complete a Preadmission Screening and Resident Review (PASARR) for one (1) of one (1) resident, Resident #60, who was reviewed with a Mental Disorder (MD) or Intellectual Disability. Findings Included: A review of the document provided by the facility titled PASRR Quick Sheet. undated revealed New Admissions: If any of the following triggers a positive response, the level 1 (MAP 409) will be checked YES on section I and/or II and contact the PASARR office. Individual has a severe mental illness/behavioral health (BH) diagnosis. Ex: Schizophrenia, Bipolar Disorder, Major Depression Disorder, Anxiety Disorder, PTSD, etc. A review of Resident #60's Face Sheet revealed the facility admitted Resident #60 on 06/09/2022 with diagnoses that included Bipolar Disorder and Depression. A review of Resident #60's PASARR completed on 06/09/2022 revealed no diagnoses listed in Section two (2): Mental Illness diagnosis. Section two (2) instructions indicated to Identify whether the resident has a current…

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, record review and interview it was determined the facility failed to maintain one freezer at safe temperatures out of the two freezers in the kitchen and the satellite kitchen. In addition, staff did not wear hairnets, wash hands, and apply gloves consistently when in the kitchen. The findings include: Observation with the Dietary Manager (DM), on 08/23/19 at 11:25 AM, revealed the freezer in the satellite kitchen had an internal temperature of 40 degrees, however the temperature reading on the gauge outside the unit showed that it was 10 degrees on the inside. Observation further revealed there was a package of okra and a package of French fries were thawed out and lying on the shelf in the freezer. Interview with the DM, on 08/23/19 at 11:25 AM, revealed the freezer had been out of commission for a while. It was cooling but not freezing. The DM stated he had put an out of service note on the freezer but it was not there now. The DM stated he did not know how long the okra and fries had been in the freezer. The DM revealed if the food had been served to 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 keep a clean and orderly environment. Observation on 08/23/19 at 9:00 AM, revealed birdseed was stored in one clean linen closet on the Downtown unit out of the seven units in the facility. Further observation, on 08/23/19 at 9:05 AM with Licensed Practical Nurse (LPN) #1, revealed the birdseed bag was opened and there were flying bugs in the bag. The findings include: Review of the facility policy Guidelines for Handling Linen, revised on 05/11/16, revealed the facility established procedures for the cleaning of linen to ensure all resident received fresh linens. The purpose of the policy was to prevent contamination of clean linens. Observation, on 08/23/19 at 9:00 AM, revealed the unlocked linen closet on the Downtown unit had resident gowns, sheets, and pillowcases on the shelves. In addition, two closed containers and one opened bag of birdseed was sitting on the floor in the clean linen room. There was birdseed lying loose on the floor under the shelves.…

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.