Franciscan Woods

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that drugs and biologicals used in the facility were be labeled in accordance with currently accepted professional principles and included the expiration date when applicable for 2 of 2 medication carts reviewed.Medication carts contained insulin that was not dated when opened and/or was expired.Findings include:The facility policy titled Insulin Administration effective [DATE] documents:Insulin is a high-risk drug and warrants additional precautions for the safe and effective administration. Insulin administration is performed by licensed nurses. Facility nursing procedures supersede this procedure if present.6. Follow the manufacturer's instruction for storage and expiration. Ensure that the opened date is documented on the vial or pen.7. Check the expiration date prior to administration to ensure it is within the usage date. Expired insulin should be immediately discarded. Vials and pens without an open date recorded 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 observation, interview, and record review, the facility did not ensure a resident's hospice notes were readily available for communication and collaboration of care in accordance with professional standards of practice for 1 (R11) of 1 residents reviewed for hospice services.Hospice visit notes were not updated in R11's medical record or in R11's hospice binder.Findings include:The facility's policy and procedure titled, Hospice Program, last approved 12/2025, documents, in part: Policy Interpretation and Implementation.D. When a resident participates in the hospice program, a coordinated plan of care between the community, hospice agency and resident/resident representative will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status.The contract titled Nursing Facility Services Agreement (Basic, Respite and General Inpatient Care for Hospice Patients) signed 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 record review, the facility did not ensure 1 (R10) of 5 residents reviewed were offered/administered the influenza vaccination. R10's Electronic Medical Record (EMR) does not contain any documentation as to whether R10 was offered, received or declined the influenza immunization. Findings include: The facility's policy titled Clinical Protocol: Influenza Vaccine, dated 09/2018, last revised 09/2022 documents: Residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. A resident's refusal of the vaccine shall be documented in the resident's medical record. R10 was admitted to the facility on [DATE] with diagnoses that includes Alzheimer's Disease (progressive irreversible brain disorder that slowly destroys memory and thinking skills), Chronic Obstructive Pulmonary Disease (COPD) (lung disease that makes breathing difficult causing airflow obstruction) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 (Coronavirus disease 2019) immunizations for 1 (R10) of 5 residents reviewed for immunizations. R10's Electronic Medical Record (EMR) does not contain any documentation as to whether R10 was offered, received or declined the COVID-19 immunization. Findings include: The facility's policy titled COVID-19, dated 06/2020, last revised 06/2025 documents: Residents will be offered the COVID-19 vaccination to remain up to date with the most current Center for Disease Control (CDC) vaccination schedule. If a resident/resident legal representative wishes to receive the COVID-19 vaccination, the facility will obtain the consent and provide the vaccination to the resident as soon as it is available in alignment with the vaccination schedule. R10 was admitted to the facility on [DATE] with diagnoses that includes Alzheimer's Disease (progressive irreversible brain disorder that slowly destroys memory…

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 did not ensure the medication error rate was below 5% during medication pass. Surveyor observed 20 out of 32 opportunities with a medication error rate of 62.5%. On 12/18/25, Surveyor observed Licensed Practical Nurse (LPN)- E stab 20 bubble packs with a pen for 2 (R8 and R9) of 4 residents during medication administration. Findings include: On 12/18/25, at 7:54 AM, Surveyor observed LPN-E administer medications to R9. R9 was administered 8 medication that included:Amlodipine 5 mg tabletCertravite (Multivitamin) 1 tabletFolic Acid 1 mg tabletHydrochlorothiazide 12.5 mg tabletTurmeric 500 mg tabletVitamin B complex 1 tabletThiamine 100 mg tabletVitamin C 500 mg tabletSurveyor observed each medication to be individually wrapped in a bubble packet and observed LPN-E lay out all 8 bubble packs on top of the medication cart and press the button on her pen to expose the ballpoint on the pen and stab each individual packet with the open ball point pen. LPN-E then placed each bubble pack over a medicine cup to push out 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 record review, interview, and facility policy review, the facility failed to prevent the physical abuse of one resident (Resident (R) 1) out of three residents reviewed for abuse out of a total sample of eight residents. This resulted in harm when R1 sustained a bruise to her wrist as well as emotional upset when a Certified Nursing Assistant (CNA)1 held her arms down while providing care. Findings include:Review of the Resident Information located under the Profile tab in the electronic medical record (EMR) revealed R1 was initially admitted to the facility on [DATE] and readmitted on [DATE].Review of R1's Care Plan, dated 07/23/25 located under the Clinical tab in the EMR, revealed R1 had impaired behavior related to refusal of cares, noncompliant with treatments, dressing changes to wounds, double and/or triple briefing, and showers. Resident is physically aggressive with staff as evidenced by slapping staff. Staff were directed to discourage double briefing due to build up of moisture. 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 record review the facility did not ensure 3 (R14 R16, and R23) of 7 residents reviewed for accidents received adequate supervision and assistance devices to prevent accidents. * R14 sustained two falls from R14's bed, 4/07/25 and 4/28/25. Staff did not to follow R14's care plan requiring 2-person assistance with bed mobility. Both falls required R14 to be transporter to the ER (emergency room) for evaluation after hitting R14's head. On 4/7/25, R14 was evaluated in the ER for 2 hematomas on R14's forehead and left cheek. On 4/28/25 R14 was evaluated in the ER (emergency room) for a bump on the back of R14's head. *R16's care plan documents the need for assist of 2 staff for transfers. R16 reported staff picked them up by the biceps and without a gait belt for a transfer and they experienced pain. The facility self report documented all staff would received education on transfers to prevent future falls. The re-education did not occur. *R23's care plan documents the need for…

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 the facility did not provide pharmaceutical services to ensure medications were available to be administered as ordered by their physician to meet their medical needs for 1 (R15) of 3 residents. R15 has an order to receive Ingrezza 40 mg (milligrams) once daily for Tardive Dyskinesia (uncontrolled involuntary muscle movements). R15 did not receive this medication on 12/3/24 & from 12/13/24 to 12/24/24. On 2/3/25 R15's Ingrezza was increased to 60 mg daily. R15 did not receive the correct dose of Ingrezza from 2/3/25 to 2/9/25. Findings include: R15 was admitted to the facility on [DATE]. Diagnoses includes congestive heart failure (heart doesn't pump enough blood to meet the body's needs), morbid obesity, drug induced subacute Dyskinesia (uncontrolled, involuntary muscle movements) and major depressive disorder. R15's hospital Discharge summary dated [DATE] includes Valbenazine Tosylate (Ingrezza) 40 mg (milligrams) with direction to take 40 mg by mouth daily. R15's nursing…

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 record review the facility did not ensure monitoring for adverse reactions to a high risk medication were implemented for 1 (R22) of 3 residents. R22 receives Eliquis (anticoagulant) 5 mg (milligram) every 12 hours for DVT (deep vein thrombosis) (blood clot) prophylaxis. The facility was not monitoring for presence of bleeding. Findings include: The facility's policy titled, Anticoagulant and last revised 12/2017 under the section Monitoring and Follow-Up documents E. The associates and physician will monitor for possible complications in individuals who are being anticoagulated, and will mange related problems. R22's diagnoses includes history of pulmonary embolism (condition where one or more arteries in the lungs are blocked by a blood clot) and long term use of anticoagulant. R22's physician orders with an order date of 4/8/24 documents Eliquis 5 mg (milligram) tablet [Apixaban] - 5 mg by mouth every 12 hours for DVT prophylaxis. R22's care plan [R22's first name] is at risk for complications from blood thinning medications. List names of medication(s): 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.

Based on record review and interview, the facility did not have documentation for investigating, and controlling, an outbreak. The facility did not document infection organisms for surveillance prevention. This had the potential to effect all 84 residents in the facility. * The facility had an influenza A outbreak in February 2025. There is no documented investigation summary for identifying, preventing and controlling, the spread of infection. * The facility on-going surveillance does not identify infection organisms. Findings include: The facility's policy and procedures Outbreak of Communicable Diseases dated 1/2024. The policy documents: The outbreaks of communicable diseases within the the community (facility) will be promptly identified and appropriately handled. The facility's policy and procedures Infection Prevention and Control Program dated 8/2024. The policy document includes: The Infection Prevention Control Program (IPCP) is designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases 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 record reviews and interviews, the facility did not implement their written policies and procedures for investigating, and reporting, allegations of abuse. This was observed with 3 (R11, R10 and R9) of 3 residents reviewed with allegations of abuse. The facility did not implement a documented, comprehensive investigative process for determining abuse which has the potential to effect all 84 residents in the facility. *R11 asked to be changed and Certified Nursing Assistant (CNA) -V stated they just started their shift and would be back, and eventually, came back. CNA-V told R11 to quit looking at the clock to see how long it's been. CNA-V told R11 to turn their light, and television off, and go to bed, however R11 wanted these on. CNA-V told R11 just because their old doesn't mean they can't learn. R11 said ouch during cares provided by CNA-V. CNA-V told R11 they are not going to help them if they keep saying ouch. * Facility Grievance Log documents R10 reported a poor interaction with a CNA on 1/29/25. A facility email by corporate human resources documents: CNA-V went…

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 3.) Surveyor reviewed a facility email which documented R11's concern with the care provided by Certified Nursing Assistant (CNA)-V. The email documented R11 asked to be changed and CNA-V stated they just started their shift and would be back, and eventually came back. CNA-V told R11 to quit looking at the clock to see how long it's been. CNA-V told R11 to turn their light and television off, and go to bed, however R11 wanted these on. CNA-V told R11 just because their old doesn't mean they can't learn. R11 said ouch during cares by CNA-V. CNA-V told R11 they are not going to help them if they keep saying ouch. On 3/20/25, at 11:23 AM, Director of Nursing (DON)-B provided Surveyor an email correspondence between corporate human resources and Unit Manager (UM)- E. DON-B was also included in the email correspondence. The email, dated 1/29/25, documents R11's concerns regarding CNA-V. The email is the only documentation of R11's care concerns related to CNA-V. DON-B stated they did not have any additional…

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 2.) On 3/18/25 Surveyor obtained, and reviewed, the facility Grievance Log. The Log documents: The date, resident, department assigned, room number, who voiced concern and summary of concern with resolved date. On 1/14/25 (R12) stated they did not like their interactions with on of the Certified Nursing Assistants (CNA). The Nurse Manager spoke with the CNA and that CNA was no longer assigned to the resident. (R12) also stated that they only are receiving 20 minutes of therapy per session. Discussed therapy session durations with therapy and (R12). Social Service (SS) followed up with (R12) regarding therapy and (R12) stated it was getting better and denied further concerns. Concern resolved 1/16/25. On 3/18/25, at 3:00 PM, at the facility exit meeting with Nursing Home Administrator (NHA) - A and Director of Nurses (DON) - B, Surveyor requested the investigation for R12's concerns. On 3/19/25, the facility had placed in the conference room, 10 interview sheets dated 1/15/25. The interview questions were related…

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 reviews and interviews, the facility did not ensure allegations of abuse were reported to the Administrator, and the State Survey Agency, as required. This was observed with 3 (R11, R10 and R9) of 3 residents reviewed for alleged abuse. *R11 alleged she asked to be changed and Certified Nursing Assistant (CNA) - V stated they just started their shift and would be back, and eventually, came back. CNA-V told R11 to quit looking at the clock to see how long it's been. CNA-V told R11 to turn their light, and television off, and go to bed, however R11 wanted these on. CNA-V told R11 just because their old doesn't mean they can't learn. R11 said ouch during cares provided by CNA-V. CNA-V told R11 they are not going to help them if they keep saying ouch. There is no evidence these concerns/interactions were reported to the Nursing Home Administrator and the State Survey Agency. *R10 reported a poor interaction with a CNA on 1/29/25. A facility email by corporate human resources documents: CNA-V went into R10's room to change them, at midnight, and told R10 not to call…

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, the facility did not comprehensively assess a resident before applying bed mobility devices. This was observed with 1 (R9) of 1 residents observed with bed mobility devices. * R9 was observed with bilateral bed mobility devices. There was not a comprehensive assessment completed. Findings include: The facility's policy and procedure Device Evaluation Form dated 1/2024. The policy documents: Any resident for whom a safety or assistive is being considered will have a Device Evaluation form completed and reviewed by the interdisciplinary team. On 3/19/25, at 12:35 AM, Surveyor observed R9 in their bed. The bed had bilateral mobility devices. R9's medical record documents in the Progress Notes: on 3/13/25 (R9) was readmitted from the hospital and is alert and oriented. (R9's) family requested bed railings on the bed. The bed rails will be installed tomorrow by maintenance. The Maintenance Work Order, dated 3/13/25, documents bed mobility devices were installed on R9's bed. R9's Device Evaluation form, dated 3/16/25, indicates no device…

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 2.) R2 admitted to the facility on [DATE]. Diagnoses include lumbar compression fracture, Depression, Dementia and moderate malnutrition. Surveyor reviewed R2's medical record. The facility admission observation/evaluation form dated 1/21/25 documented no skin impairments. Facility progress notes dated 1/23/25 documented R2 had increased combativeness, increased agitation during PM shift, husband witnessed and apologetic for behaviors. Facility progress note dated 1/24/24 documented a left forearm skin tear 3 x 3 x 0.1. 100% flap. Steri strips placed, foam border dressing - change 3 times a week or PRN (as needed). Surveyor noted the Treatment Administration Record (TAR) did not include treatment orders for the skin tear and there was no other documentation in the nursing progress notes regarding the skin tear. Facility progress note dated 1/31/24 documented a new order left forearm skin tear: Xerofoam, bordered foam dressing change 3 times a week and PRN. Keflex 500 milligrams four times daily x 5 days for…

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 the facility did not ensure 1 (R1) of 2 residents reviewed for anticoagulant medication were free from unnecessary medications. * R1 received warfarin (anticoagulant) without adequate monitoring by ensuring PT/INR (prothrombin time test and international normalized ration) labs were conducted. On 12/25/24 R1 had orders for the lab to draw a PT (PT)/International Normalized Ratio (INR). The lab was not drawn until 12/31/24 and R1 was given his Warfarin from 12/23/24 to 12/31/24. R1's results from the PT/INR on 12/31/24 was 5.8 which was above therapeutic level of 2-3. (A high PT/INR level indicates the blood is clotting more slowly than normal.) Findings include: R1 was admitted to the facility on [DATE] with diagnoses including left femur fracture with surgical intervention, history of cerebral infarct and longtime use of anticoagulants. R1's care plan, initiated 1/3/25, documented, Potential for complications from blood thinning medications due to warfarin, with a goal…

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, interviews, and record review the facility did not provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's, to meet the needs of each resident for 1 of 3 (R185) residents reviewed for medications. R185 did not receive an antibiotic as indicated on the hospital discharge summary. Findings include: R185 admitted to the facility on [DATE] with diagnoses that include small bowel obstruction, hypertension, acute kidney injury superimposed on chronic kidney disease, Failure to thrive, demand ischemia and Peripheral Artery Disease. R185 discharged to the hospital for a clogged gastrostomy tube on 11/11/24 and did not return to the facility. Surveyor asked DON (Director of Nursing)-B for a facility policy and procedure regarding admission orders and transcribing of orders. DON-B reported the facility did not have a policy related to admission orders or transcribing orders. DON-B provided…

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, and document review, the facility failed to ensure there were sufficient staff adequately deployed to meet six out of 26 sampled residents needs (Resident (R)186, R40, R15, R45, R27, and R184). Residents were double briefed, waited too long for call lights to be answered, did not get timely incontinence care/toileting, showers, or the provision of hygiene. Residents remained in bed due to the fear staff would not put them back to bed in time if they got up. Agency staff (internal pool and outside pool) were frequently used. Residents, families, and staff reported agency staff were not well trained/aware of residents' needs. Findings include: 1. Review of the undated Profile Face Sheet in the electronic medical record (EMR) under the Profile tab revealed R186 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and muscle weakness. Review of the quarterly Minimum Data Set (MDS) with an…

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 policy review, the facility failed to ensure dietary staff adhered to proper glove use/hand hygiene when serving meals to 15 residents residing on the west side of the second floor. This created the potential for cross contamination and spread of food borne illness. Findings include: Review of the facility's Disposable Glove Use policy dated 01/2023 and provided by the facility revealed, Disposable gloves must be changed, and hands washed when the gloves are dirty or ripped and when moving from one task to another . Observation on 11/11/24 at 9:02 AM of meal service in the kitchenette on the west side of the second floor. Dietary Aide (DA)1 was serving food from a steam table to residents who resided on the west side of the second floor. DA1 dished up three plates of breakfast which included scrambled eggs and breakfast meat. DA1 scooped the scrambled eggs and meat onto these plates and then repositioned the food on the plate using her gloved hands. In between touching the ready to eat food, she touched the paper tray cards, plates, and utensils.…

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, interviews, record review, policy review, and Centers for Disease Control (CDC) guidance, the facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) for two of 18 residents (Resident (R)15, and 40) reviewed for enhanced barrier precautions (EBP) when direct care was provided. The facility staff failed to clean and disinfect patient equipment used for three of eight residents (R24, R48, and R68) reviewed for infection control. These failures could promote the spread of multi-drug-resistant organisms (MDROs) throughout the facility. Findings include: 1. Review of R40's undated admission Record in the Profile tab of the electronic medical record (EMR) revealed an admission date of 04/08/19 and diagnosis of moderate protein-calorie malnutrition. Review of R40's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/16/24, located in the EMR MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated R40 was severely cognitively impaired. During an observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure one out of 26 sampled residents' (Resident (R)40) Responsible Party (RP) was notified of changes in condition for R40. Specifically, the RP was not notified when R40 developed a new pressure injury and when he sustained purple marks to his right arm pit. Findings include: Review of the facility's policy titled, Change in a Resident's condition or Status dated 01/2024 and provided by the facility revealed, Our community shall promptly notify the resident, his or her health care provider, and representative of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's health care provider or physician on call when there has been a (an): 1. Accident or incident involving the resident; 2. Discover of injuries of an unknown source; . 4. significant change in the resident's physical/emotional/mental condition . Review of the undated Profile Face Sheet in the Electronic Medical Record (EMR)…

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 policy review, the facility failed to address a grievance from the Responsible Party (RP) regarding the care for one of 26 sample residents (Resident (R)186). This created the potential for R186's needs to go unmet. Findings include: Review of the facility's policy titled, Complaints and Grievances dated 05/2023 and provided by the facility revealed, It is the policy of Ascension Living to provide residents and family members/legal representative the opportunity to voice complaints and grievances . Such complaints or grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished . Definitions . Grievance - Any moderately complex complaint or service issue received verbally or in writing from residents or resident representative regarding treatment or services that require intervention and a written resolution letter. All written complaints received by residents or resident representatives through any means…

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 policy review, the facility failed to ensure that a written transfer notice was provided to a resident and the resident's responsible party when one of one resident (R)23) reviewed for hospitalization was transferred to the hospital. This had the potential to affect the resident and the resident's responsible party understanding the reason for the transfer and the resident's right to appeal. Findings include: During an interview on 11/11/24 at 10:37 AM, R23 stated she went to the hospital. She stated she did not remember the date that she was sent to the hospital and that she did not remember receiving a written transfer notice. Review of R23's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/07/24 and located in the MDS tab of the electronic medical record (EMR) revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. Review of R23's progress notes located in the ID notes section of the EMR revealed a nurse's note dated 08/23/24 and at 11:14 PM which indicated…

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, and policy review, the facility failed to ensure two out of four sampled residents (Resident (R)40 and R186) reviewed for activities of daily living (ADLS) were provided with adequate assistance to maintain cleanliness and hygiene. R186 and R40 were not provided with adequate assistance with toileting, incontinence care, and baths/showers. Findings include: Review of the facility's policy titled, Clinical Protocol: Urinary Incontinence dated 01/2024 provided by the facility revealed, As part of the initial assessment, continence status will be identified through interview of resident/resident representative and review of the resident's medical record . As appropriate, based on assessment of the category and causes of incontinence the associate will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status . 1. Review of the undated Profile Face Sheet in the electronic medical record (EMR) under 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, record review, and policy review, the facility failed to ensure one out of five residents (Resident (R)40) reviewed for unnecessary medications did not receive an unnecessary medication. R40 was prescribed an anti-anxiety medication on an as needed (PRN) basis without a stop date identified. Findings include: Review of the facility's Psychotropic Medication policy dated 10/2024 and provided by the facility revealed, Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. The need to continue PRN orders for psychotropic medication beyond 14 days requires that the practitioner document the rationale for the extended order. The specific duration for the PRN order will be indicated in the order. Review of the undated Profile Face Sheet in the Electronic Medical Record (EMR) under the Profile tab revealed R40 was admitted to the facility on [DATE] with diagnoses including dementia…

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, record review, and facility policy review, the facility failed to document the provision of activities of daily living (ADLs), the percentage of meals eaten, and the administration of scheduled treatments for 4 (R1, R2, R4, and R5) of 18 sampled residents. Findings included: 1. A review of a facility policy titled, Shower/Tub Bath, revised in February 2024, revealed, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The policy indicated, The following information should be recorded on the resident's ADL record and /or in the resident's medical record: A. The date and time the shower/tub bath was performed. B. All assessment data (e.g., any reddened areas, sores, etc. [et cetera, other similar things], on the resident's skin) obtained during the shower/tub bath. C. How the resident tolerated the shower/tub bath. D. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. E. The signature and title of the person recording the data. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility did not report allegations to the State Agency within the required timeframes. This was discovered with 4 (R41, R9, R116, and R10) of 5 Facility Reportable Incidents. -R41 alleged physical abuse by staff and this was not reported to the State Agency within 2 hours as required. -R9 sustained rib fractures of unknown origin that were not reported at all to the State Agency as required. -R116 had an allegation of sexual misconduct of a staff that was not reported to the State Agency within the 24 hours and 5-day required timeframes. -R10 had an allegation of neglect with an injury that was not reported to the State Agency within 2 hours as required. Findings include: Surveyor reviewed the facility's policy and procedure Abuse Prevention revised 6/2022. The Abuse Prevention policy documents the following: Monitoring and Follow UP: Monitoring, documentation and applicable interventions will be completed by clinical associates; Prevention: Identification, ongoing…

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 interviews and record reviews, the facility did not ensure allegations of abuse were thoroughly investigated, including preventative/corrective action. This was discovered with 4 (R41, R36, R9, and R116) of 4 Facility Reportable Incidents (FRI). -R41 had an allegation of physical abuse by staff that was not thoroughly investigated, including preventative action. -R36 had an allegation of verbal abuse investigated without preventive/corrective action. -R9 had an injury of unknown origin of rib fractures that was not thoroughly investigated, including preventative/corrective action. -R116 had an allegation of sexual misconduct by staff that was not thoroughly investigated. Findings include: Surveyor reviewed the facility's policy and procedure on Abuse Investigation and Reporting revised 10/23. The procedures include: interview resident, staff and anyone with potential information; reviewing medical record for events leading up to event; witness reports will be obtained in writing, signed and dated.…

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 the facility did not ensure 1 (R9) of 18 residents reviewed for quality of care, received care and treatment in accordance with professional standards of practice. * On 8/10/23 at 9:00 pm, R9 slipped off her bed and fell to the floor. There was no Registered Nurse (RN) assessment completed after this fall prior to transferring R9 back into bed. R9 was not added to the facility's 24-hour board for monitoring of R9 after the fall. There were conflicting investigative statements, where Licensed Practical Nurse (LPN)-I reported Certified Nursing Assistant (CNA)-J transferred R9 back into bed alone while CNA-J indicated the nurse came and helped get R9 up. There was no call to R9's responsible party or MD. There is no documentation on 8/10/23 regarding this fall. On 8/14/23 R9 complained of pain, denying fall or injury. The physician assistant was updated and R9 was transported to the hospital, where R9 was diagnosed with multiple fractures of the left sided ribs. The 8/18/23, 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 observations, interviews and record review the facility did not ensure that residents received care, consistent with professional standards of practice, to prevent pressure injuries and residents with pressure injuries received the necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing for 2 of 6 (R23 and R19 ) residents reviewed for pressure injuries. * R23 did not have a comprehensive assessment or measurements of her stage 4 sacral pressure injury upon admission and was missing consistent weekly assessments and measurements. * R19 was observed to not have heels offloaded when in bed. Findings include: The facility procedure titled, Pressure Injury Assessment/Treatment dated last approved August, 2023 documents (in part) .The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified pressure injuries, alterations in skin integrity, and the prevention of…

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 did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's to meet the needs of each resident. Expired medications were observed in 1 of 2 unit refrigerators which involved 1 discharged resident (R1A) and 1 of 3 medication carts observed which involved (R30). Findings include The facility policy titled Medication Disposal and Returns effective 6/21/17 documents (in part) . .3. Nursing staff shall dispose of any discontinued and expired medications that have been opened, or are not returnable to the pharmacy in accordance with policies and procedures. Policy: Facilities will dispose of discontinued and expired medications that are not returnable to the pharmacy in accordance with local State and Federal regulations and per facility protocols. The facility policy titled Medication Administration effective 6/21/17 documents (in part) . 5. Multi-dose vials: a. After initial use are to be labeled with date opened 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility did not ensure residents psychotropic medications were adequately monitored for indications for use. This was observed with 2 (R18 and R55) of 5 residents reviewed on psychotropic medications. * R18 was admitted on antianxiety and anti-depressant medications without behavioral indications for use and monitoring. * R55 was admitted on antipsychotics and antianxiety medication without behavioral indications for use and monitoring. This is evidenced by: Policy Review: Behavioral Assessments, Interventions and Monitoring last revised 12/2019 Procedure(includes) C. Residents with behavioral expressions and those on a psychotropic medication will have their behaviors monitored routinely. D. Specific, individualized, interventions will be put into place to aide in behavior management that includes non- pharmacological modalities. 1. The interdisciplinary Team will meet to review and discuss the following: a. specific resident behavior b. Appropriateness 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.