Franciscan Post-Acute Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan for one of five sampled residents (Resident 1) when Resident 1 had known behaviors of getting up unassisted from bed, refusing to use his walker, call light and TLSO brace (thoracolumbosacral orthosis, is a type of back brace used to limit motion and promote healing in the thoracic [upper midback] spine, lumbar [lower back] spine, and sacral [triangular bone at the base of the lumbar spine connecting the spine to the pelvis] areas) and the facility did not develop and implement interventions that were person-specific in the comprehensive care plan. This failure placed Resident 1 at risk for falls and had the potential for pain and complications from his L1 fracture (a break in the first vertebra of the lower back [lumbar spine]). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure services provided met professional standards of practice for one of five sampled residents (Resident 1) when Resident 1 sustained an L1 fracture (a break in the first vertebra of the lower back [lumbar spine]) during a fall at the facility on 3/25/26 and was hospitalized , the resident returned to the facility on 3/30/26 with an order from the acute care hospital to wear a TLSO (thoracolumbosacral orthosis, is a type of back brace used to limit motion and promote healing in the thoracic [upper midback] spine, lumbar, and sacral [triangular bone at the base of the lumbar spine connecting the spine to the pelvis] areas) brace while ambulating (ability to walk) and the facility did not enter the order or follow up with Resident 1's physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one of three sampled Residents (Resident 2) when Certified Nursing Assistant (CNA) 1 completed a two-person required mechanical lift (a mobile floor lift system that rolls on wheels and is intended to lift, suspend and transfer a medically dependent person from a bed, shower, toilet or wheelchair) transfer without assistance. This failure placed Resident 2 at risk for falls and significant injuries.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for one of six sampled residents (Resident 1) when: 1. Resident 1 was admitted to the facility with diagnoses of Type 2 Diabetes Mellitus (Type 2 DM- a disorder in which blood sugar or glucose levels are abnormally high) and licensed nursing staff did not develop an individualized care plan intervention to monitor Resident 1's blood glucose levels, from 5/4/25 to 5/18/25. This failure resulted in Resident 1 experiencing significant change in condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's food preferences were honored for one of six sampled residents (Resident 3) when sliced tomatoes was placed on Resident 3's lunch plate despite tomatoes being listed as a dislike. This failure had the potential to result in decreased food intake, and could result in unplanned weight loss, compromising Resident 3's nutritional and medical status.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to refer a resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASARR) when 2 (Resident #4 and Resident #11) of 2 sampled residents reviewed for PASARR were diagnosed with a new serious mental illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address the risk of fire while smoking for one of three sampled residents (Resident 1), when staff were aware of Resident 1's need for oxygen (a colorless, odorless gas that is essential for life), history of smoking and bringing in cigarettes and lighters into the facility and did not implement effective measures to ensure Resident 1's safety from fire. These failures resulted in Resident 1 smoking unnoticed while wearing oxygen on 2/4/25, catching fire and suffered avoidable second-degree burns (injury that damages both the outer layer of skin and part of the underlying layer) to the face and right forearm, swelling and severe pain, requiring emergency transport to a higher level of care and hospital with a Burn Unit (a hospital ward that treats patients with burns). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-a resident assessment tool used to identify resident cognitive and physical function) accurately reflected resident ' s health and functional status for one of three sampled residents (Resident 1) when Resident 1 ' s smoking status and oxygen use were not accurately coded on the MDS assessment. This failure had the potential for Resident 1's smoking and oxygen safety care needs to go unmet. (cross reference F689)

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan to prevent accidents for one of three sampled residents (Resident 1) when nursing staff was aware of Resident 1 ' s smoking status, attempts to bring cigarettes and lighters into the facility without staff knowledge and previous attempts at smoking while wearing oxygen at the facility and did not develop and implement effective care plan interventions to prevent smoking related injuries. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Resident 1, 2 and 4) were free from abuse when: 1. Staff failed to separate Residents 1 and 2 immediately after an altercation on 12/25/24 at 3:00 p.m., then Resident 2 sat next to Resident 1 in the sunroom and scratched Resident 1 in the face while the CNA ' s back was turned. Residents 1 and 2 had a known history of verbal altercations with each other. This failure had the potential to cause both residents harm and emotional distress due to cognitive (pertaining to reasoning memory and judgement) impairments. 2. Staff did not provide adequate supervision for Resident 1 after the altercation on 12/25/24 at 3:00 p.m. to prevent an altercation between Residents 1 and 4 on 12/25/24 at 4:40 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide rehabilitative services as determined by the comprehensive plan of care to attain, maintain, and restore the highest practicable level of physical well-being for one of three sampled residents (Resident 1) when Resident 1 did not receive physical therapy (PT) as ordered by the physician. This failure placed Resident 1 at risk for further decline and not meet rehabilitative goals.

Inspectors wroteBased on observation, interview, and record review, the facility to ensure services provided met professional standards of practice for one of four sampled residents (Resident 1) when the facility staff failed to perform hourly monitoring of Resident 1 in accordance with the facility ' s policy and procedure (P&P) titled, Rounding Using the 4 P ' s Rounding Tool. This failure had the potential to result for Resident 1 to fall and suffer significant injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from an unnecessary physical restraint (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; or cannot be removed easily by the resident; and or restricts the resident's freedom of movement or normal access to his/her body) for three of six sampled residents (Residents 2, 3 and 4) when Residents 2, 3 and 4 had wedge pillows (triangular pillow to elevate the body) intentionally placed under their mattresses, out of their reach, restricting the residents freedom of movement and prevented them from getting out of bed. This failure violated Resident 2, 3 and 4 ' s rights to be free from physical restraints and placed them at risk for a decline in physical functioning and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 1) was free from injury when his shoeless left foot fell off his wheelchair and scraped on the pavement while out of the facility for an appointment. This failure resulted in Resident 1 experiencing abrasions to four of his toes on his left foot which caused pain, daily dressing changes by nursing staff, and an increased risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of nine sampled residents (Resident 1), when Resident 1 was diagnosed with dementia (a chronic or persistent disorder of the mental processes marked by memory disorder, personality changes, and impaired reasoning), and a known history of poor safety awareness and muscle weakness and contracture (shortening of muscular or connective tissue that results in deformity) of left hand; and was not supervised while she drank hot tea on 2/16/22, in accordance with comprehensive care plan which indicated Resident 1 was totally dependent on staff to eat and drink. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) were free from physical abuse when Resident 2 who had a known behavior of aggression and history of altercation pushed Resident 1 down to the ground on 1/25/2024. This failure resulted in Resident 1 to sustain a laceration to her elbow, skin tear to her forehead, and bruising to her face.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of three sampled residents (Resident 1) when Licensed Nurses did not accurately document Resident 1's tube feeding and water flush totals accurately in Resident 1's Medication Administration Record (MAR). This failure had the potential for Resident 1 to be administered more fluids (tube feeding and water flushes) than ordered.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, wheno ne of three License Nurses (Licensed Vocational Nurse 1) did not know how to set up a suction machine and did not receive training on suctioning. This failure placed residents at risk for respiratory distress which could lead to death.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's current Covid-19 (an infectious disease caused by the SARS-CoV-2) virus status for seven of 62 sampled residents (Residents 6, 16, 23, 25, 31, 58, and 59 and) when: 1. Resident 6's COVID-19 status was inaccurately coded in the MDS assessment as currently having active COVID-19 and Resident 6 did not have an active COVID-19 diagnosis. 2. Resident 16's COVID-19 status was inaccurately coded in the MDS assessment as currently having active COVID-19 and Resident 16 did not have an active COVID-19 diagnosis. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory (network of organs and tissues that help you breathe) care and services in accordance with professional standards of practice for three of three sampled residents (Residents13,19, and 64) when: 1. Resident 13's nasal cannula, (a tube placed in the nose used to deliver supplemental oxygen) was not dated and labeled. 2. Resident 19's nasal cannula was not dated and labeled. 3. Resident 25's nasal cannula was not dated and labeled. These failures had the potential to result in cross contamination and placed Residents 13, 19 and 25 at risk to develop infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety when: 1. A roll of masking tape and two grey kitchen trays were stored under the shelving in the dry storage. 2) Three packages of hamburger buns were not labeled with a received date or used by date These failures placed residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when Licensed Vocational Nurse (LVN) 2 failed to perform hand hygiene during medication administration. This failure had the potential to result in the transmission of infection between residents

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary, orderly and comfortable homelike environment for eight of 38 sampled residents (Resident 7, Resident 22, Resident 35, Resident 37, Resident 47, Resident 16, Resident 39, and Resident 58) when: 1. Residents' 22, 35, and 47 shared restroom was left with dried feces on the toilet seat riser. 2. Residents' 7, 16, 37, 39, and 58 shared toilet was left with clumped unflushed toilet paper, wet sheets of paper towels and rolled toilet paper on the restroom floor. These failures resulted in an unsanitary and unhomelike environment to Residents 7, 16, 22, 35, 37, 39, 47, and 58.

Inspectors wroteBased on observation, interview, , and record review, the facility failed to implement comprehensive resident-centered care plans (a plan that provides direction for individualized care of the resident) for two of two sampled residents (Resident 8 and Resident 54) when: smoking paraphernalia was stored by the residents instead of the nursing station as indicated in the residents care plan. This failure had the potential for residents smoking safety needs to go unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment free from accident hazards and implement interventions to reduce smoking risk in accordance to facility's policy and procedure for two of two sampled residents (Resident 8 and Resident 54) when Resident 8 and Resident 54's smoking paraphernalia were on resident's possession and stored in resident's room. This practice failied to comply with the facility safety policy and procedure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection control and prevention program to prevent the development and transmission of communicable diseases and infections when: 1. Resident 47, Resident 35, and Resident 22 shared restroom was left soiled with dried feces on the toilet seat riser. 2. Certified Nursing Assistants (CNA 3 and CNA 4 ) did not perform hand hygiene between patient meal tray set up for four of 38 sampled residents (Residents' 16, 34, 54, and 215). This failure lead to the potential of cross contamination (transfer of bacteria from one surface to another) from staff's ineffective infection control practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize resident's individuality and ensure residents were treated with dignity and respect for one of 38 sampled residents (Resident 54) when Resident 54's bed preference for his bed placement was not honored. This failure resulted in the facility not honoring Resident 38's bed placement which exposed him to feel the draft of cold or during the night.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to attain or maintain the highest practical well-being for one of 38 sampled residents (Resident 64), when the facility failed to ensure weekly wound measurements were completed for pressure ulcers (a localized damage to the skin and underlying soft tissue usually over a bony prominence related to direct pressure) This failure posed a potential risk for Resident 64's pressure ulcers to deteriorate and decline without being unnoticed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records were accurately documented for one of 38 sampled residents (Resident 13) when Resident 13's location of the vascular (related to a vessel of the body which carries blood) access for dialysis (the process of removing waste products and excess fluids from the body) was not accurately identified. This deficient practice had the potential to result in confusion in the care and services for Resident 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a functional, sanitary, and comfortable environment for five of 38 sampled residents (Resident 7, Resident 16, Resident 37, Resident 39, and Resident 58) when: their shared restroom toilet was clogged with clumped toilet paper which could not be flushed. This failure resulted in an inoperable toilet for Resident 7, 16, 37, 39 and 58.