Franciscan Village

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was provided adequate assistance during bed mobility to prevent injury. This failure resulted in R1 requiring hospitalization for treatment of a femur fracture. This applies to 1 of 3 residents reviewed for skin impairments in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe transfer mobility for a resident who is dependent on staff for transfer assistance. This failure resulted to R118 falling from her wheelchair and sustaining fracture injury. In addition, the facility also failed to follow recommended transfer assistance and appropriate use of assistive devices for residents who are identified as high-risk for falls. This applies to 4 of 4 residents (R10, R43, R52, R118) reviewed for accidents and supervision in the sample of 19.

Inspectors wroteBased on observations, interview and record review, the facility failed to prepare food, clean dishes and store pots and pans in sanitary conditions. This applies to all 97 residents that receive food prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that their controlled substance medications were completely sealed in their packaging. This applies to 7 of 7 residents (R8, R10, R35, R44, R50, R60, R65) reviewed for medication storage in the sample of 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide fortified foods for residents that had a recommendation for the same. This applies to 6 of 6 residents (R18, R35, R45, R64, R78, R95) reviewed for fortified foods in the sample of 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow menu spreadsheets to serve portions for main entree for residents receiving mechanical soft diets. This applies to 4 of 4 residents (R73, R96, R117 and R119) reviewed for dining in the sample of 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow diet guidance for mechanical soft diets. This applies to 6 of 6 residents (R20, R23, R47, R52 and R84) reviewed for mechanical soft diets in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance to residents requiring staff assistance with ADLs (Activities of Daily Living). This applies to 2 of 3 residents (R22 and R117) reviewed for ADL care in the sample of 19.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to assess and provide interventions for a resident exhibiting pain during care. This failure applies to 1 of 3 (R117) reviewed for pain management from a total sample of 19The

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for medication administration. There were 28 medication opportunities with 2 errors resulting in 7.14% error rate. This applies to 1 of 6 residents (R100) reviewed for medication pass in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provisions of activities of daily living (ADL) care. This applies to 3 of 4 residents (R36, R43, R52), reviewed for infection control in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain monthly weights/reweights and recognize significant weight loss for a resident. This failure resulted in R82's weight loss not being recognized until R82 sustained a 12.47% weight loss in 90 days. This applies to 1 resident (R82) reviewed for weight loss in a sample of 34 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired food items from the dry storage and failed to properly store food items in the freezer by building ice on food packages, the walk-in freezer door side, and the floor. This applies to all 98 residents consuming food from the kitchen. The Findings Include: On 8/6/24 at 9:42 AM, during an initial kitchen tour with the dietary manager (V5), the kitchen dry storage was observed with one-quarter of 32-ounce (oz) peanuts expired on 7/24/24, one pound of opened Pistachio bag expired on 7/25/24, an opened almond bag with two pounds of almonds expired on 7/25/24, and an unopened white chocolate designer dessert sauce 16 oz expired on 11/2021. On 8/6/24 at 9:45 AM, V5 stated, Everyone, especially the stock person, is responsible for checking for expired food items, which should be discarded. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to residents dependent on staff for personal hygiene and grooming. This applies to 10 of 10 residents (R12, R26, R30, R42, R44, R45, R49, R51, R59, and R68) reviewed for ADL's in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to do hand hygiene and glove change during incontinence care, wound care, and during the meal service. The facility also failed to use proper PPE (Personal Protective Equipment) for residents who were under EBP (Enhanced Barrier Precautions) during wound care. This applies to 6 residents (R45, R92, R68, R60, R14, and R96) reviewed for infection control in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to put call lights within reach for residents. This applies to 3 of 3 resident (R52, R54, R56) reviewed for accommodation of needs in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to invite 2 residents (R45, and R68) to their care plan meetings that were reviewed for care plans, in a sample of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for 2 residents (R45 & R68) in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative nursing programs to residents identified with limited range of motion. This applies to 3 of 3 residents (R8, R53, and R55) reviewed for limited range of motion in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to put fall mats in place for R77, who was at a high fall risk. This applies to 1 of 1 resident (R77) reviewed for accidents and supervision in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 6 of 7 residents (R6, R12, R22, R65, R73 and R81) reviewed for ADLs (activities of daily living) in the sample of 21.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve pureed consistency Chicken Cacciatore and vegetables to residents on pureed diets. This applies 5 of 5 residents (R16, R21, R28, R67, R350) reviewed for pureed diets in the sample of 21.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve nutrition supplements and diet consistency as ordered by the Physician. This applies to 4 of 5 residents (R16, R34, R87, R88) reviewed for dining in the sample of 21.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to offer residents the pneumococcal vaccine. This applies to 6 of 6 residents (R6, R14, R15, R22, R33, and R67) reviewed for immunizations in the sample of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and provide supportive device to residents, to prevent further reduction in ROM (range of motion). This applies to 2 of 6 residents (R65 and R81) reviewed for range of motion in the sample of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received medication to treat hemorrhoidal pain. This applies to 1 of 1 resident (R44) reviewed for pain in a sample of 21.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications as ordered by the physician. There were 28 opportunities with 5 errors, resulting in 17.85% medication error rate. This applies to 3 of 5 residents (R24, R44 and R350) observed during the medication pass in the sample of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that 2 residents were given medications as prescribed by their physicians for Parkinson's disease and to prevent blood clotting. This applies to 2 of 2 residents (R16 and R57) reviewed for significant medication errors in a sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was accessible to a resident if they were lying on the bathroom floor. This applies to 1 of 1 resident (R352) reviewed for call light accessibility in the sample of 21.