Franciscan Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure the continuous positive airway pressure machine (CPAP) was properly cleaned and maintained for 1 of 1 resident (R15) reviewed for respiratory care.Findings include:R15's annual Minimum Data Set (MDS) dated [DATE], indicated R15 was cognitively intact. Section O: Special Treatments, Procedures, and Programs was not coded for CPAP.R15's face sheet dated 2/27/26, included diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, congestive heart failure, and obstructive sleep apnea.R15's care plan revised 11/24/25, included CPAP settings but did not address standard cleaning and maintenance of CPAP for infection prevention.R15's provider orders dated 2/27/26, included:CPAP: staff to set up at HS and when in bed for naps. every shift Startup CPAP as machine is preprogrammed and will adjust to inhalation pressure needsNo evidence of orders for cleaning and maintenance of R15's CPAP…

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 document review the facility failed to offer influenza and pneumococcal vaccinations and or provide education according to Centers for Disease Control (CDC) guidelines for 3 of 5 residents (R12, R13, R8) reviewed for vaccinations.Findings include:R12's significant change Minimum Data Set (MDS) dated [DATE], identified R12 had diagnoses which included malignant neoplasm of right renal pelvis, hypothyroidism, dementia, and hypertension. A review of R12's immunization record identified they received the influenza vaccine on 11/4/25, education given was documented as no.R13's comprehensive MDS dated [DATE], identified R13 had diagnoses which included atrial fibrillation (fast, irregular heart rate), gastroesophageal reflux disease (GERD), benign prostatic hyperplasia (BPH [noncancerous enlargement of the prostate gland]), hyperlipidemia, arthritis, and depression.A review of R13's Vaccination Consent form dated 9/17/25, identified they wanted to receive the influenza vaccine during 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure residents were educated on COVID-19 vaccinations when administered to 1 of 5 residents (R8).Findings include:R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 had diagnoses which included vascular dementia, depression, bipolar disorder, chronic pain, and post-traumatic stress disorder (PTSD).A review of R8's immunization record identified they received the Covid-19 vaccination on 11/4/25, education given was documented as no.During an interview on 2/26/26 at 12:18 p.m., the acting director of nursing acting (DON) stated when residents were admitted they received the Vaccine Information Statement (VIS) in their admission packet.During an interview on 2/26/26 at 3:36 p.m., the nurse consultant (NC)-B stated when vaccines were given new consents were obtained and new education was given along with a VIS.Resident Immunizations dated 1/21/25, identified the facility would offer vaccinations based on the Centers for Disease Control…

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 interviews and record review the facility failed to report an allegation of sexual assault within 2 hours to the State Agency (SA) for 2 of 3 clients (R1, R2) when reviewed for abuse. Findings include:Facility incident report dated 1/20/26 indicated on the morning of 1/20/26 at approximately 9:15 a.m., registered nurse (RN)-A reported R1 came to the dining room to greet his wife (R3) when an aide asked R1 to move to passed him. R1 moved and continued around the table to his wife (R3) and came behind R2 and groped her breasts without R2's consent. R1 was redirected to his room and was educated on the matter. R1 had little to no remorse for the action he had made towards R2. RN-A stated R2 was aware the incident happened, but shortly after R1 groped her she closed her eyes and showed no visual negative reaction or distress. R2 was later interviewed by staff and had slight to no recall on the incident. Police were called and R1 and R2's responsible parties were notified. RN-A who reported the incident had not worked at the facility for a length of time and was not aware 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure there were sufficient numbers of staff to ensure all resident cares were completed timely for 4 of 7 residents (R8, R23, R15, R22) who received their morning medications late, in addition for a resident with pressure ulcers needing assistance turning and repositioning for 1 of 3 residents (R25). This deficient practice had the potential to affect all 39 residents who resided in the facility. Findings include: Free of Medication errors of 5 percent or more see also F759 R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 was moderately cognitively intact and had diagnoses which included, gastro-intestinal appliance, anxiety, depression, surgical aftercare following a surgery on the digestive system, dysphagia (difficulty swallowing foods or liquids arising from the throat or esophagus, ranging from mild to difficult to complete and painful blockage), nutritional deficiency, and history of malignant neoplasm of other…

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 document review the facility failed to ensure medications and supplies available for use in a the medication storage room were not expired. This had the potential to affect all 39 residents residing in the facility. Findings include: On 12/11/24 at 1:35 p.m., during an inspection of the locked medication room with the director of nursing (DON) the following observations were made: -lab cart for blood draws had nine yellow top blood tubes with an expiration date of 10/31/24 -all four respiratory viral panel swabs were expired -two bottles of hibiclens had expiration dates of 8/2024 and 11/2024 -two tubes of Bacitracin ointment with expiration dates of 11/2023 During an interview on 12/11/24 at 2:09 p.m., the DON stated would not want to use expired medications as could not be sure of their potency and efficacy. The DON stated it was the responsibility of the night shift to check for out dated supplies but they did not have any check off sheet to ensure it was completed. Night Nurse Weekly Duties undated, identified each Tuesday the night nurse…

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, and document review, the facility failed to ensure current contact information of all pertinent State Agency and advocacy groups were posted at a level accessible to all residents. This had the potential to affect all residents who chose to view this information. Findings include: On 12/9/24 at 6:51 p.m., the resident council president gave permission to review the resident council meetings. The resident council meetings revealed rights were not reviewed at the 12/4/24, and 11/4/24, resident council meeting but were reviewed at the 10/7/24, and the 9/3/24, meeting. On 12/10/24 at 1:26 p.m., a resident council meeting was held with four residents in attendance (R2, R17, R12, and R26) all of whom required the use of a wheelchair. The four residents in attendance did not know where the state inspections were posted and volunteered some of the postings were too high to read for residents in a wheelchair and with poor eyesight. On 12/10/24 at 2:05 p.m., the large bulletin board in the main dining room was reviewed. The poster for information regarding the ombudsman…

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 document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 13.79% with 4 errors out of 29 opportunities for error involving 1 of 7 residents (R8) who were observed during the medication passes. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 was moderately cognitively intact and had diagnoses which included, gastro-intestinal appliance, anxiety, depression, surgical aftercare following a surgery on the digestive system, dysphagia (difficulty swallowing foods or liquids arising from the throat or esophagus, ranging from mild to difficult to complete and painful blockage), nutritional deficiency, and history of malignant neoplasm of other organ system. R8's Physician Order Review as of 12/12/24, identified the following orders: fluoxetine 10 milligrams (mg) one tablet into gastric tube one time per day every day at morning 7:00 a.m.-10:00 a.m…

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 document review the facility failed to ensure resident call lights were within reach from the bathroom floor in multi -resident bathrooms for 5 of 5 residents (R3, R15, R23, R40, R22) reviewed for call light accessibility. Findings include: On 12/12/24 at 8:22 a.m., the following bathroom call lights were observed: room [ROOM NUMBER] call light did not reach the floor, there were several knots in the cord. room [ROOM NUMBER] call light was short approximately 12 inches in length and did not reach the floor. room [ROOM NUMBER] call light was short approximately 15 inches from the floor. room [ROOM NUMBER] call light would not turn on when the cord was pulled. room [ROOM NUMBER] call light was approximately 12 inches in length and did not reach the floor. During an interview on 12/12/24 at 9:43 a.m., nursing assistant (NA)-D stated he thought call light cords in the bathroom had to reach below the toilet. NA-D could not recall any education on the length of the call light cord…

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 document review the facility failed to ensure a copy of the baseline care plan was provided to the resident and/or representative for 1 of 3 residents (R40) reviewed who was a new admission. Findings include: R40's Resident Face Sheet dated 12/12/24, identified R40 was admitted on [DATE], with spastic hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting right dominant side and nontraumatic intercerebral hemorrhage. R40's 48 hour baseline care plan dated 11/19/24, identified R40's short term goals, health maintenance needs, pain intervention, safety concerns, medication concerns, and designated representative. R40's 48 hour baseline care plan identified needs and interventions for the following: eating, toileting, bathing, grooming, dressing, bed mobility, and transfers. However, the 48 hour baseline care plan lacked any indication that R40 or R40's representative had been offered or received a copy of the 48…

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 document review, the facility failed to ensure timely repositioning for a resident with pressure ulcers (PU) for 1 of 2 residents (R25) reviewed for PU care. Findings include: R25's significant change in status assessment (SCSA) minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of Parkinson's with dyskinesia, diabetes mellitus, stage two PU of sacral region, stage two PU of left buttock, dermatitis due to friction or contact with body fluids, non-pressure chronic ulcer of skin limited to breakdown of skin. R25 was dependent on staff for bed mobility. R25's care plan dated 1/5/23, identified dependence on staff to reposition in bed every two to three hours. R25 was incontinent of bowels and needed assistance after each episode with staff to check every two hours. During a continuous observation starting 12/12/24 at 8:14 a.m., R25 was observed in bed with the head of bed at about 20 degrees, with the bend in the bed partway up his back. R25 didn't…

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 document review, the facility failed to implement communication system with an outside dialysis facility to promote continuity of care and reduce the risk of complication for 1 of 1 resident (R21) reviewed for dialysis care. Findings include: R21's comprehensive Minimum Data Set (MDS) dated [DATE], identified R21 had intact cognition along with diagnoses of end stage renal disease and type 2 diabetes mellitus. R21's MDS also indicated resident received dialysis care while residing at the nursing facility. R21's care plan identified resident admitted to nursing facility on 11/6/24. Care plan identified resident received dialysis on Monday, Wednesday, and Friday. It identified staff actions of assessing dialysis site for bleeding or drainage and to update provider or dialysis unit with any concerns, recording weights from dialysis unit, and to observe resident for signs and symptoms of infection (redness, warmth, swelling) to access site, and to notify provider or dialysis unit with…

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 document review, the facility failed to investigate, review, and analyze underlying causes of resident's delusions for 1 of 1 resident (R11) who was reviewed for behaviors. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had no cognitive impairment and diagnoses included congestive heart failure, type 2 diabetes mellitus, hypo-osmality and hyponatremia (condition of having abnormally low levels of electrolytes and other fluids in the blood),, paroxysmal atrial fibrillation (an irregular heartbeat that comes and goes), hypertension, cirrhosis of the liver, depression, hyperlipidemia, and spontaneous bacterial peritonitis (bacterial infection in abdominal fluids without an obvious source for the infection). R11's MDS had exhibited behaviors of hallucinations and delusions within the previous seven days. R11's care plan dated 10/28/24, identified R11 had short term memory problems and/or periods of confusion/disorientation/forgetfulness. Care…

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 document review, the facility failed to ensure appropriate use of personal protective equipment (PPE) when exiting a resident's room (R32) with a Covid-19 positive diagnosis. Findings include: R32's significant change Minimum Data Set (MDS) dated [DATE], identified R32 was severely cognitively impaired and had a diagnosis of Covid-19. On 12/11/24 at 1:05 p.m., two staff were observed outside of R32's room, they both donned isolation gowns, removed their surgical masks and then put on N-95 masks, then put on gloves, knocked and entered R32's room. R32's door had a sign up indicating airborne precautions need to be followed. PPE supplies were hanging on the door, there were no trash receptacles outside of the room. On 12/11/24 at 1:15 p.m., Nursing assistants (NA)-B and NA-E were observed exiting R32's room wearing surgical masks. NA-B stated they doffed (removed) their N-95 masks in the room and put on clean surgical masks that were stored inside the room. NA-B stated they had…

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 document review, the facility failed to ensure immunization records were up to date for 2 of 5 residents (R13, R40) who were new admissions. In addition, the facility failed to ensure residents and/or resident representatives were educated on and residents offered pneumococcal vaccines (vaccines given to prevent pneumonia) upon admission for 1 of 5 residents (R17). The facility further failed to provide education and offer the influenza vaccine to 3 of 5 residents (R11, R13, R40) reviewed for immunizations. Findings include: Immunization Records R13's Resident Face Sheet identified R13 was admitted on [DATE], was over the age of 50 and had diagnoses which included hypertensive heart disease, anxiety disorder, atrial fibrillation and flutter (a condition in which the heart beats too fast and irregularly and rapid heart rate that is organized and repetitive but still faster than normal), and adult failure to thrive. A review of R13's record did not reveal a Minnesota Immunization Information…

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 document review, the facility failed to ensure residents were educated on and offered COVID-19 vaccinations upon admission to 3 of 5 residents (R11, R13, R40). Findings include: R11's Resident Face Sheet identified R11 was admitted on [DATE], and had diagnoses which included chronic heart failure, hypertension, multidrug resistant organism (MDRO), diabetes mellitus, and depression. R11's immunization record identified R11's last COVID-19 vaccine was on 10/19/23. R13's Resident Face Sheet identified R13 was admitted on [DATE], was over the age of 50 and had diagnoses which included hypertensive heart disease, anxiety disorder, atrial fibrillation and flutter (a condition in which the heart beats too fast and irregularly and rapid heart rate that is organized and repetitive but still faster than normal), and adult failure to thrive. A review of R13's record did not reveal a Minnesota Immunization Information Connection (MIIC) report. The facility was not able to provide any immunization…

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 document review, the facility failed to protect a resident's right to be free from sexual abuse by staff for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1's Face Sheet undated, identified R1 had schizoaffective disorder, autistic disorder, bipolar disorder, intellectual disabilities, Alzheimer's disease, dementia, and schizophrenia. An Annual Notice of Right to Petition for Termination or Modification of Guardianship or Other Relief dated 6/3/24 indicated R1 had a court appointed guardian due to his inability to be his own decision maker. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment, delusions, and needed extensive assistance with all cares, and supervision for eating. R1's care plan dated 2/23/24, indicated R1 makes inappropriate sexual comments and may touch others inappropriately. Interventions included cares in pairs, redirect R1, remove R1 from the situation, and observe R1 during meals and activities. On 8/6/24 at…

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 document review, the facility failed to ensure allegations of sexual abuse were reported immediately (within two hours) to the State Agency (SA) for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1's Face Sheet undated, identified R1 had schizoaffective disorder, autistic disorder, bipolar disorder, intellectual disabilities, Alzheimer's disease, dementia, and schizophrenia. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment, delusions, and needed extensive assistance with all cares, and supervision for eating. On 8/6/24 at 11:57 a.m., a progress note by registered nurse (RN)-A indicated R1 stated to RN-A that he had a girlfriend from housekeeping. R1 stated they loved each other, and she came in his room, and they touched each other. On 8/8/24 at 1:50 p.m., R1 stated two to three days ago he met housekeeper (H)-A, and she came into his room. He touched her breast and vagina with his hands, and they kissed. He knew he 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.

Based on interview, and document review, the facility failed to ensure required abuse, neglect, and exploitation training was completed for 1 of 3 staff (housekeeper [H]-A) whose personnel records were reviewed. Findings include: On 8/9/24 at 8:38 a.m., H-A stated she did not recall the last time she had abuse, neglect, and exploitation training. Review of personnel files on 8/9/24, indicated H-A had not had training on abuse, neglect, and exploitation since 6/7/21. On 8/9/24 at 12:11 p.m., the director of nursing (DON) stated every staff should have abuse training upon hire, annually, and as events occur. On 8/9/24 at 12:33 p.m., the administrator stated H-A has had no education on abuse, neglect, and exploitation since 2021. Staff should have this education upon hire and annually. A facility policy titled Maltreatment Prohibition policy reviewed 10/18/21 directed employees would be trained on Maltreatment Prohibition polices and procedures during the orientation process, and on an annual basis.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure allegations of physical abuse were reported immediately (within two hours) to the State Agency (SA) for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1's care plan dated 10/3/22, identified R1 was alert and oriented. R1's annual Minimum Data Set (MDS) dated [DATE], identified R1 had verbal and physical behaviors towards others, and needed extensive assistance with bed mobility, transfers, and toilet use. R1's progress note written on 3/12/24 at 10:30 p.m., by registered nurse (RN)-A indicated R1 stated staff hit his pacemaker with metal. On 3/15/24 at 12:50 p.m., R1 stated on 3/12/24, RN-A came into his room, and she threw his bed remote at him hitting him in the pacemaker. R1 stated he told staff at the facility, and at the hospital what happened. R1's progress note on 3/15/24 at 9:59 p.m., written by RN-A indicated R1 stated the nurse threw him down the basement stairs and he hit his head. On 3/19/24 at 9:20 a.m., RN-B stated…

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 document review, the facility failed to ensure an allegation of potential physical abuse was thoroughly investigated and adequate resident protection provided to ensure safety for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1's care plan dated 10/3/22, identified R1 was alert and oriented. R1's annual Minimum Data Set (MDS) dated [DATE], identified R1 had verbal and physical behaviors towards others and needed extensive assistance with bed mobility, transfers, and toilet use. R1's progress note written on 3/12/24 at 10:30 p.m., by registered nurse (RN)-A indicated R1 stated staff hit his pacemaker with metal. On 3/15/24 at 12:50 p.m., R1 stated on 3/12/24, RN-A came into his room, and she threw his bed remote at him hitting him in the pacemaker. R1 stated he told staff at the facility, and at the hospital what happened. R1's progress note on 3/15/24 at 9:59 p.m., written by RN-A indicated R1 stated the nurse threw him down the basement stairs and he hit his head. On…

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 document review the facility failed to ensure residents with trust accounts received quarterly statements for 1 of 1 residents (R7) reviewed for resident funds. This had the potential to affect 58 current and discharged residents who had personal accounts managed by the facility. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact. During an interview on 10/2/23 at 1:12 p.m., R7 stated they never received statements from the facility for their personal trust account. During an interview on 10/4/23 at 3:13 p.m. the administrator confirmed resident trust account statements were not sent out since his start date of 1/3/23. The facility had 58 residents with a trust account at the facility. Residents and/or their representative should receive quarterly trust account statements. The Trust Fund Monthly Summary, dated 10/4/23, identified there were 58 residents with current trust accounts at the facility; however, not all residents residing in…

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 and document review, the facility failed to ensure the surety bond was equal to or greater than the resident funds entrusted to the facility. This had the potential to affect all 58 current and discharged residents who had personal accounts managed by the facility. Findings include: The Bond Transaction Summary dated 10/1/23, identified the facility had a $25,000.00 surety bond that was issued by Nationwide Mutual Insurance company. The Trust Fund Monthly Summary dated 10/4/23, indicated the facility had 58 current/ discharged residents with trust fund accounts at the facility. The total balance of the trust accounts was listed as $44,433.61. During an interview on 10/4/23 at 3:13 p.m., the administrator stated the total trust account balance was $31,947.85 and the facility surety bond was for $25,000.00, which did not cover the current trust account balance made up of funds from 58 residents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to honor individual preferences for early morning toileting for 1 of 4 residents (R7) reviewed for choices. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact. R7's undated, Facesheet identified R7 had multiple sclerosis and major depression and a history of urinary tract infection. R7's care plan dated 8/17/23, directed staff to check and change R7's brief at 5:00 a.m. R7 had a history of urinary tract infections. During an interview on 10/2/23 at 1:27 p.m., R7 stated they repeatedly told staff they wanted staff to wake them up at 5:00 a.m., but it was not getting done. R7 shared this request with managers. If the night staff didn't get R7 up at 5:00 a.m. R7 usually had to wait until around 7:00 a.m. to get assistance to the bathroom. During an interview on 10/4/23 at 7:37 a.m., R7 reported they had woken up around 6:00 a.m. and had to call for staff to come in. R7 did not recall what time they got…

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 document review, the facility failed to comprehensively assess psychotropic medications using the Resident Assessment Instrument (RAI) process for 1 of 5 residents (R26) reviewed for unnecessary medications. Findings include: R26's annual Minimum Data Set (MDS) dated [DATE], identified R26 had severe cognitive impairment. R26 received 7 days of antipsychotic and antidepressant medication during the Assessment Reference Date (ARD). Section V 0200 of the Care Area Assessment (CAA) and care planning, identified psychotropic drug use had triggered for completion. An undated, unlabeled document identified R26 started Seroquel 25 mg daily on 12/21/22, and listed anxiousness, restlessness and sleep as targeted behaviors for Seroquel. R26's Psychoactive Medication Informed Consent Form dated 5/30/22, indicated R26 was taking sertraline for the target behavior of decreased mood. R26's medical record lacked evidence CAA's had been completed for psychotropic medication. During an interview on 10/4/23…

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 document review, the facility failed to perform activities of daily living (ADL's) for 1 of 6 residents (R24) reviewed for ADL's. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 had severe cognitive impairment and required extensive physical assistance of one person personal hygiene. Diagnoses included progressive neurological decline and non-Alzheimer's dementia. R24's care plan dated 9/7/23, instructed staff to shave R24's face daily. During an observation on 10/2/23 at 2:27 p.m., R27 had whisker stubble along the sides of his face, chin, and upper lip. During an observation on 10/3/23 at 12:44 p.m., R27 continued to have whisker stubble along the sides of his face, chin, and upper lip. During an observation on 10/3/23 at 4:00 p.m., R27 continued to have whisker stubble on his face, his hair was wet and combed back. During an observation on 10/4/23 at 11:01 a.m., R27 was located in the dining room seated in a wheelchair, dressed, glasses…

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 document review the facility failed to ensure oxygen tubing was changed according to policy for 1 of 1 residents (R10) reviewed for respiratory care. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 was cognitively intact. Diagnoses included end stage renal disease and chronic respiratory failure. R10's undated Resident Face Sheet, included an order for oxygen 1 liter per minute to keep oxygen levels above 90 percent three times daily, there was no order for oxygen tubing to be changed weekly. R10's care plan dated 8/16/23, instructed the use of oxygen for comfort care. During an observation on 10/2/23 at 2:49 p.m., R10 was in bed wearing nasal cannula oxygen tubing with oxygen running. The tubing was connected to a large oxygen concentrator in the room. There was not a visible change date on R10's oxygen tubing. During an observation on 10/3/23 at 1:30 p.m., R10 was in bed with nasal cannula on and oxygen running. During an observation on…

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 document review the facility failed to implement anticoagulant side-effect monitoring for 1 of 2 resident (R12) reviewed for anticoagulant use. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of hypertension and peripheral vascular disease or peripheral arterial disease. R12 was cognitively intact and an anticoagulant was used during the last seven days prior to the completion of the MDS. R12's current provider orders dated 3/4/22, directed staff to administer Xarelto (a blood thinner that can only be monitored by observation) 20 milligrams (mg) daily. R12's care plan dated 5/25/22, failed to identify R12's interventions related to anticoagulant use or that R12 was on anticoagulant. During interview on 10/5/23 at 11:13 a.m., nursing assistant (NA)-A stated the nursing assistants refer to electronic medical record to know how to care for and monitor each resident. There was nobody on NA-A's unit that was on a blood thinner and needed…

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 document review, the facility failed provide evidence of non-pharmalogical interventions prior to the admininistration of as-needed (PRN) psychotropic medications and identify behavior monitoring for 1 of 5 residents (R34); and failed to identify behavior and side effect monitoring 1 of 5 (R26) residents reviewed for unnecessary medication use. Findings include: R34's significant change Minimum Data Set (MDS) dated [DATE], identified diagnoses of dementia and Parkinson's disease. R34 was cognitively intact and had behaviors of rejection of cares. The cooresponding Care Area Assessment (CAA) dated 8/4/23, identified specific areas to address were behavioral symptoms and psychotropic drug use. R34's care plan dated 11/2/22, indicated a care plan for mental health behaviors was initiated but lacked goals and interventions staff would try to assist the resident back to baseline. R34's Doctor's Orders form dated 8/17/23, directed staff to administer Alprazolam oral tablet 0.5 milligram (mg)…

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 record review the facility failed to ensure resident lifts were effectively sanitize prior to being used on other residents for 3 of 3 residents (R18, R31, R37) observed during lift transfers. Findings include: During observation on 10/2/23 at 2:18 p.m., certified occupational therapy assistant (COTA)-D entered R18's room, transferred R18 with the assist to stand, R18 physically touched the lift. After the transfer COTA-D took the lift back to the hallway without sanitizing the lift. During observation on 10/2/23 at 2:31 p.m., nurse assistant (NA)-B gathered the unsanitized assist to stand lift, entered R31's room, and transferred R31 from the chair to commode and back without sanitizing the lift. NA-B exited the room without sanitizing the lift. As NA-B was exiting the room NA-C grabbed the lift without it being sanitized and entered R37's room. NA-C used the lift to transfer R37 to the bed, and returned the unsanitized lift to the hallway without sanitizing it. During observation on 10/2/23 at 2:41 p.m., NA-D gathered the unsanitized lift 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.