Franklin Restorative Care Center

Inspectors wroteBased on observation, interview, and document review, the facility failed to develop and implement effective interventions to prevent resident-to-resident physical abuse for 3 of 3 residents (R1, R2, and R3) reviewed for abuse. This resulted in the likelihood of serious harm, injury, or death when on 7/9/26 R1 wandered into R2's room and began choking R2, requiring staff intervention to separate the residents. After, R1 continued to exhibit wandering behaviors and on 7/15/26 R1 wandered into R3's room and the two exchanged punches before staff could intervene. These findings constituted an Immediate Jeopardy (IJ) situation. The Immediate Jeopardy began on 7/9/26 when the facility failed to implement and maintain effective interventions following the resident-to-resident choking incident involving R1 and R2. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess falls and injuries, identify causal factors and implement interventions to decrease the risk of fall or injury for 2 of 3 residents (R1 and R4) reviewed for injury and falls.

Inspectors wroteBased on interview, video/audio recording review and document review, the facility administration directed staff not to report or document a resident elopement. The administration's direction not to report, prevented immediate identification and correction of failures in supervision, alarm response, staff training, and elopement prevention, leaving residents exposed to continued risk of elopement and serious injury and demonstrated a breakdown of the facility's governing systems for resident protection, quality assurance, and promoted an ongoing culture of fear of the facility being shut down, retaliation and regulatory noncompliance. [...]

Inspectors wroteBased on interview, observation and document reviews, the facility failed to adequately supervise and maintain resident safety when resident (R4), with a history of exiting the facility unsupervised, eloped through the front door of the facility, and drove an employee vehicle in the parking lot. This resulted in an Immediate Jeopardy (IJ) situation for R4. In addition, the facility failed to implement a system to ensure adequate supervision was provided for R4, when the exit alarm system panel was not labeled to alert staff to the exit door that R4 opened. The IJ began on 6/6/2026, when R4, who was assessed to be an elopement risk, was exhibiting exit seeking behavior just prior to the incident, exited through the front door of the facility, was able to enter an employee's vehicle with the keys inside, and drove across the employee parking lot before being observed by staff. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure call lights were functional and within reach for 3 of 8 residents (R1, R5, and R7) reviewed for call light placement.

Inspectors wroteBased on interview and record review the facility failed to notify the resident representative regarding changes to skin integrity, weight loss, and accidents for 1 of 1 residents (R1) reviewed for change in condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an elopement from the facility was recognized and reported to the state agency (SA) for 1 of 1 resident (R4) reviewed for elopement.

Inspectors wroteBased on interview and document review the facility failed to thoroughly investigate a report of elopement for 1 of 1 resident (R4).

Inspectors wroteBased on interview and document review, the facility failed to monitor, report, and implement timely interventions for 1 of 2 residents (R1) reviewed for significant weight loss.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the infection prevention and control program included ongoing surveillance, analysis, and trending of resident and staff infections. Additionally, the facility failed to maintain knowledge of a current list of reportable communicable diseases, including when and to whom communicable diseases, healthcare-associated infections, and potential outbreaks must be reported. This had the potential to affect all 34 residents who resided in the facility. In addition, the facility failed to ensure adherence to enhanced barrier precautions (EBP) when nursing staff failed to wear personal protective equipment (gowns) when providing direct care to 2 of 2 residents (R4, R22) reviewed for pressure wounds.

Inspectors wroteBased on interview and document review the facility failed to implement and maintain an effective infection prevention and control program specific to antibiotic stewardship. The facility did not have a system to track antibiotic use, culture results, organisms identified, or antibiotic resistance to ensure residents received appropriate treatment, this had the ability to affect all 34 residents. Findings Include:Review of the Infection Prevention and Control (IPC) case list dated 1/1/26-3/31/26, , documentation included resident name, room number, onset date, signs and symptoms, current prescription, prescriber, infection type, organism, diagnosis, and category. However, the log lacked documentation of the date cultures were obtained, organisms identified from culture results, and whether organisms were resistant to prescribed antibiotics. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents were free from involuntary seclusion when the facility maintained locked exit doors that prevented residents from freely exiting the building, without conducting individualized assessments, clinical justification, or care planning to support the restriction. This deficient practice had the potential to affect 8 of 34 residents (R4, R6, R11, R16, R20, R7, R29, R39) residing at the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure medications were coded accurately on the Minimum Data Set (MDS) assessments for 2 of 5 residents (R11 and R29) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to report elevated blood glucose levels per provider order for 1 of 1 residents (R5) reviewed for insulin. In addition, the facility failed to calibrate blood glucose monitors according to manufacturer instructions for 1 of 1 residents (R5) reviewed for insulin. Further, the facility failed to ensure monitoring of skin wounds for 1 of 1 resident (R22) reviewed for non-pressure skin conditions.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow provider orders for wound care dressing changes for 1 of 1 resident (R4) reviewed for pressure injury.

Inspectors wroteBased on interview and document review, the facility failed to ensure consulting pharmacist recommendations were addressed or acted upon for 2 of 5 residents (R8, R28) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day for 5 of 7 days reviewed. This had the potential to affect all 34 residents living in the facility.

Inspectors wroteI'm not sure if this is correct, I used other surveyors tags as guidiance, and their tag from last year. Let me know if you want me to change anything. Based on interview and document review the facility failed to ensure a registered nurse (RN) was scheduled for at least 8 consecutive hours a day, seven days a week. This had the potential to affect at 35 residents who reside in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all required data were included on the nurse staffing information posted daily. This had the potential to affect all 35 residents residing in the facility and their visitors who may wish to view the information.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure dishwasher temperatures were within the manufactures minimum temperatures to ensure resident dishes were sanitized. In addition, the facility failed to ensure temperatures were monitored in 4 of 4 refrigerators and 2 of 2 freezers reviewed for the kitchen. This had the potential to affect all 35 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program effectively sustained ongoing compliance related to repeat citations from past surveys regarding immunizations. This had the potential to affect all 35 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to obtain informed consent, including risks and benefits, for 4 out of 4 residents (R8, R15, R22, R27) reviewed for use of psychotropic medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement a system to monitor stored narcotics to prevent diversion. This had the potential to affect all 16 residents prescribed Schedule II-V medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure pharmacist consultant recommendations were acted upon for 5 of 5 residents (R8, R15, R22, R24, R27) reviewed for unnecessary medications.

Inspectors wroteBased on document review, interview, and observation the facility failed to ensure shared resident refrigerator 1 of 1 was kept in sanitary conditions and 2 of 2 (shared resident refrigerator and medication refrigerator) reviewed for temperature control were monitored.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a self-administration of medications assessment was completed, and orders obtained, for all medications kept at bedside for 1 of 1 residents (R24) observed with medications at their bedside.

Inspectors wroteBased on interview and record review the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN-CMS-10055) was provided to 1 of 3 residents (R143) reviewed for beneficiary notification.

Inspectors wroteBased on observations, interviews and document review, the facility failed to ensure resident living areas were free from unwanted noise for 3 of 4 residents (R3, R14, R22) reviewed for uncomfortable sound levels. This had the potential to affect residents in surrounding rooms, visitors and facility staff.

Inspectors wroteBased on interview and document review the facility failed to ensure ordered as needed (PRN) antipsychotic medications were limited to a 14-day time period and clinical rational indicated continuation past the 14-day time period. Additionally, the facility failed to ensure a gradual dose reduction (GDR) or appropriate indication for use for medications was documented for 2 of 4 residents (R15, and R27) reviewed for unnecessary medications.

Inspectors wroteBased on record review and interviews the facility failed to update the care plan for 1 of 2 residents (R31) reviewed for pressure ulcer interventions.

Inspectors wroteBased on record review and interview the facility failed to accurately implement physician orders for 1 of 1 resident (R5) reviewed for weekly weight monitoring.

Inspectors wroteBased on observation and interview, the facility failed to maintain separately locked and permanently affixed compartments for storage of controlled medications in the medication room refrigerator reviewed for medication storage.

Inspectors wroteBased on interview and document review, the facility failed to ensure 3 of 5 residents (R10, R27, R31) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s).

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 residents (R26) reviewed for immunizations were offered and/or provided the COVID-19 vaccine to help reduce the risk of associated infection(s).

Inspectors wroteBased on interview and document review, the facility failed to ensure physician orders were followed for pressure ulcer (PU) wound care for 3 of 3 resident (R1, R4, and R5) reviewed for wound care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper hand hygiene was performed during wound care for 2 of 3 residents (R4 and R5) reviewed for wound care.

Inspectors wroteBased on interview, observation, and document review the facility failed to thoroughly investigate falls, establish adequate fall prevention interventions, and follow care planned fall interventions for 2 of 3 residents (R1 and R5) reviewed for falls. This resulted in actual harm when R1 fell and required a visit to the emergency department resulting in a fractured left tenth rib.

Inspectors wroteThe facility's request for a waiver was accepted and approved by the State Agency following the survey dated 12/22/22. The tag was re-issued however NO plan of correction is required. This will remain in effect until such time as the registered nurse (RN) coverage can be filled and the facility achieves compliance. F727: CFR 483.35 (b)(1), RN coverage 8 consecutive hours a day, 7 days a week.

Inspectors wroteBased on document review and interview, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 1) 2024 (October 1 - December 31) to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS.

Inspectors wroteBased on interview and document review, the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 34 residents.

Inspectors wroteBased on interview and document review, the facility failed to have evidence of 1 of 1 Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 34 residents.

Inspectors wroteBased on interview and document review, the facility failed to provide mandatory training on 1 of 1 facility specific Quality Assurance Performance Improvement (QAPI) Program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program.

Inspectors wroteBased on interview and document review, the facility failed to notify the county (designated State Mental Health Authority (SMHA)) when 1 of 1 resident (R15) with new on-set of mental illness.

Inspectors wroteBased on interview and document review, the facility failed to offer and/or administer the most recent Centers for Disease Control (CDC) pneumococcal vaccine for 2 of 5 residents (R22 and R32) reviewed for immunizations. Furthermore, the facility failed to have a method or system to ensure the facility offer or provided any initial or updated vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations.

Inspectors wroteBased on interview and document review the facility failed to report an allegation of injury of unknown origin with serious bodily injury timely to the State Agency (SA) for 1 of 1 resident (R1) reviewed who had injury of unknown origin.