Franciscan Woods

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 3 of 3 residents (R5, R7, and R1) reviewed for falls. *R5 was transferred by mechanical lift by one Certified Nursing Assistant (CNA.) The CNA was not following R5's care plan to transfer residents with two staff members when using a mechanical lift. R5 slid out of the sling and sustained multiple rib fractures. *R7 was transferred from bed to a motorized scooter via a sling. The sling was left under R7 while R7 was in the motorized scooter. R7 slipped out of R7's scooter and R7 sustained a right leg fracture. After the fall with fracture, facility Physical Therapy (PT) staff informed Surveyor that the motorized scooter that R7 had been using was not safe for R7. [...]

Inspectors wroteBased on record reviews and interviews, the facility did not ensure allegations of sexual abuse were reported to the State Survey Agency, within 5 working days of the incident. This was observed with 1 of 1 Facility Reported Incidents reviewed for alleged sexual abuse.* NHA-A did not submit an investigation of findings for allegations of sexual abuse involving R1 within 5 days to the State Agency. Findings Include:The Facility's policy, titled Abuse Prevention with a last revised date of 08/2025, indicates, in part, the following .The community will investigate and report any allegations of abuse within timeframes as required by federal, state, and local requirements. R1 was admitted to the facility on [DATE] and was sent out to the hospital on 5/18/2026 for unrelated medical concerns. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 (R2) of 3 allegations of abuse or neglect reviewed.*R2 was found with a bruise and new skin tears and the injuries were of unknown origin. The investigation was not thoroughly investigated as nursing documentation and staff statements were conflicting.

Inspectors wroteBased on interviews and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 2 (R7 and R1) of 2 residents reviewed for unwitnessed falls. *R7 sustained an unwitnessed fall on 4/17/26. Facility staff did not document that neurological checks were completed per facility fall protocol and standards of practice. *R1 sustained multiple unwitnessed falls. No RN (Registered Nurse) assessment was completed after R1 experienced two falls. Facility staff did not document that neurological checks were completed per facility fall protocol and standards of practice for four falls.

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 51 residents. The facility was not monitoring infections, tracking and trending infections and monthly infection rates were not completed in the facility for 2025. In November 2025, the facility did not have any documentation of monitoring infections, surveillance, tracking and trending of infections were not completed, and infection rates were not completed. The facility had a Covid 19 outbreak in September 2025, and the infectious outbreak was not thoroughly investigated. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure they implemented an effective antibiotic stewardship program with the potential to affect all 51 residents in the facility. Review of the facility infection surveillance logs for residents on antibiotics, indicate antibiotic use without documentation of appropriate use, surveillance, and tracking information.

Inspectors wroteBased on interview and record review, the facility did not ensure that a written consent explaining the risks and benefits of psychotropic medications was obtained for 2 (R10 and R11) of 5 Residents who's medication records were reviewed. *R11 was prescribed Lorazepam, a benzodiazepine that works in the brain to relieve symptoms of anxiety. The facility did not have a signed consent explaining the risks and benefits of Lorazepam. *R10 was prescribed Zyprexa, an antipsychotic medication that helps regulate mood, behaviors and thoughts. The facility did not have a signed consent explaining the risks and benefits of Zyprexa. Findings Include: The facility's policy and procedure titled, Medication Monitoring, effective date 6/21/2017, documents: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 (R5, R8 and R9) of 4 residents reviewed for transfers or discharges received the proper written notice of transfer, written bed hold policy with reserve bed payment identified and that proper notification was sent to the State Long-Term Care Ombudsman. * R5 was transferred to the hospital on 9/14/25 and 10/20/25, for evaluation due to a change in condition with no evidence of written bed hold notice and transfer notice provided to R5. The State Ombudsman was not sent a copy of the notices. * R8 was transferred and admitted to the hospital on [DATE], while residing in the facility and evidence was not provided that R8 or their representative were notified in writing of the reason for the transfer/discharge to the hospital and the facility policy for bed hold, including reserve bed payment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a resident who is unable to carry out activities of daily living receive the necessary services to maintain good nutrition and assistance with meals for 1 of 15 (R1) residents observed during meals. R1's meal tray was not set up and R1 was not positioned upright to eat and R1 was not provided assistance with meals per R1's plan of care.

Inspectors wroteBased on interview and record review, the facility did not ensure that based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan for the followed for 1 (R10) of 5 residents reviewed. R10's physician order for daily weights every day and to notify provider if greater than 3 pound change in one day or greater than 5 pounds in a week was not implemented per R10's physicians order. occur.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with pressure injuries or at risk for pressure injury development received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries and to promote healing for 1 (R12) of 4 residents reviewed for pressure injuries.* R12 was admitted to the facility with a sling to the left arm. There is no evidence of monitoring the skin under the sling and R12 developed an unstageable pressure injury that declined to a stage 4 pressure injury to R12's left elbow with exposed hardware. Interventions were not implemented timely to prevent R12's pressure injury from developing/ declining.

Inspectors wroteBased on interview and record review, the facility did not ensure residents received adequate supervision to prevent accidents for 1 (R9) of 1 residents reviewed for smoking.*R9 smokes and the facility lacked ongoing smoking supervision and assessments or a cessation program. The facility's policy and procedure titled, Smoking Policy-Residents, last revised 10/2025 documents in part: Policy Statement- This policy is established to maintain safe resident smoking practices in accordance with the fire safety regulations. Residents who wish to smoke on the community premises should comply with the requirements in the policy. Smoking is defined as a practice in which a substance, most commonly tobacco, is burned and the smoke is tasted or inhaled. This policy applies to the use of all smoking materials, consumed by cigarette, pipe, vaporizers, electronic cigarettes and other vapor devices. F. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R8) of 1 residents who is fed by enteral means received the appropriate treatment and services to prevent complication from enteral feeding. R8 received an enteral feed and a flush was not done prior to starting the feeding per R8's physician order.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services for 1 (R55) of 15 residents reviewed. R55 was not provided multiple medications per physician orders and not signed out as given on the Medication Administration Record (MAR) dated January 2026 through April 2026.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, and record review the facility did not ensure residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries and to promote healing for 1 (R2) of 2 residents reviewed with pressure injuries. R2 was admitted to the facility on [DATE], with a diagnosis of Type 2 Diabetes. There is no documentation the facility was performing daily diabetic foot checks as documented in R2's care plan. R2's care plan does not document person centered interventions of turning and repositioning when R2 is assessed to be dependent on the staff for activities of daily living (ADLs). On 11/1/25, R2's family notified the facility of R2 having bilateral heel pressure injuries. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote3.) R7 was admitted to the facility on [DATE] with diagnoses that include, Subarachnoid hemorrhage, Dementia, Palliative care, Anxiety, Depression, Muscle contracture of right and left knee. R7's Quarterly Minimum Data Set assessment dated [DATE] documents R7 is severely cognitively impaired. R7 is dependent for all cares and transfers. R7 requires substantial/maximum assist for bed mobility. R7 is at risk for pressure injuries but does not have a current pressure injury. R7 is always incontinent of bowel and bladder. R7 has an activated healthcare Power of Attorney (POA) and is currently on hospice. R7's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 8/16/24 documents, in part: Pressure ulcers CAA triggered secondary to potential and presence of actual pressure ulcer . [...]

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure residents maintained acceptable parameters of nutritional status for 1 (R6) of 1 resident reviewed for weight loss. R6 experienced severe weight loss over a period of 6 months, during which time R6 developed pressure injuries. The weight loss was not prescribed, and no new interventions were implemented to prevent R6's weight loss. Surveyor was unable to locate any documentation that the Facility updated the Power of Attorney or R6's physician.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wrote3.) 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. [...]

Inspectors wrote2.) 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure residents received care, consistent with professional standards of practice, and the necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing for that 1 (R3) of 3 residents reviewed for pressure injuries. * R3 did not receive pressure injury treatments for a pressure injury that was discovered during admission. There was no evidence that R3's physician was notified of R3's newly discovered pressure injury and there was a delay in implementing pressure relieving interventions and pressure injury treatments for R3. During this delay, R3's pressure injury increased in size and the condition deteriorated while they were not receiving treatment and interventions.

Inspectors wrote2.) 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. [...]

Inspectors wroteBased 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.)

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one out of two sampled residents (Resident (R)185) reviewed for tube feeding was provided with tube feeding administration in accordance with physician's orders. The facility failed to administer the prescribed formula and failed to ensure medication (pills) were crushed. R185 was hospitalized on [DATE] with a clogged feeding tube. The facility staff administered R185 medications in a pill form that were not sufficiently crushed which clogged the feeding tube. R185 was hospitalized and a surgical procedure was necessary to unclog the feeding tube due to the pill lodged in the tube.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the nurse staff information contained the resident census, failed to post it daily, and failed to maintain the nurse staffing data for a minimum of 18 months. This deficient practice had the potential to affect all residents and visitors being uninformed about the facility's staffing status.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and record review the facility did not implement their abuse prevention policy by ensuring 3 of 8 facility staff had the necessary background information disclosure (BID) form completed upon hire in order to work at the facility. The BID form is 1 of a 3 part screening process which requires applicants/employees to disclose various information such as; if they have any criminal charges pending against them, if they have ever been convicted of a crime in federal, state, local, military, and tribal courts, if any government agency found the individual to have committed child abuse or neglect or if they have ever been found to have abused or neglected any person or client. This deficient practice had the potential for affect all 74 residents residing in the facility at the time of the survey. [...]