Health Center at Franklin Park

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide activities designed to support residents' physical, mental and psychosocial well-being were provided for one (#10) of four residents reviewed for meaningful activity programming activities out of 32 sample residents and on one of three units. Specifically, the facility failed to:-Offer and provide a personalized activity program for Resident #10;-Ensure Resident #10 was invited and encouraged to attend activities of the resident's preference; and,-Ensure a meaningful activities program was consistently provided to residents residing in the facility's secured dementia care unit.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of three medication carts. Specifically, the facility failed to ensure residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened.

Inspectors wroteBased on observations and interviews, the facility failed to maintain emergency response carts and equipment in safe operating condition for three of five emergency (crash) carts. Specifically, the facility failed to:-Ensure staff completed daily equipment checks;-Ensure expired items were removed from the crash cart;-Ensure missing items were replaced on the crash cart; and,-Ensure staff had knowledge of which electrical outlets were connected to the emergency backup generator.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#28 and #55) of five residents were free from chemical restraints out of 32 sample residents. Specifically, the facility failed to: -Ensure Resident #28's representative was informed of the facility's decision to implement a gradual dose reduction (GDR) after the pharmacist and the physician recommended a GDR of the resident's Zyprexa (antipsychotic medication);-Ensure Resident #55's antipsychotic medication was appropriately monitored and reviewed by the interdisciplinary team (IDT); and, -Ensure Resident #55's care plan included resident-specific non-pharamacological care approaches for the resident's behaviors.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure received services and assistance to prevent a reduction in range of motion for two (#6 and #10) of four residents reviewed for range of motion out of 32 sample residents. Specifically, the facility failed to: -Ensure preventative measures were put into place for Resident #6's bilateral hand contractures; and, -Ensure preventative measures were followed for Resident #10 to prevent further body misalignment.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in two of three units. Specifically, the facility failed to: -Ensure resident rooms were cleaned in a sanitary manner; -Ensure manufacturer recommended surface contact times were followed for effective disinfection; -Ensure resident glucometers were cleaned in a sanitary manner; and, -Ensure gloves were worn while administering an insulin injection.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents were kept free from abuse for one (#30) of three residents reviewed for abuse out of 23 sample residents. Specifically, the facility failed to protect Resident #165 from physical abuse from Resident #30.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#21) of three residents out of 23 sample residents investigated for abuse. Specifically, the facility failed to report two allegations of verbal abuse of unidentified residents by Resident #21 to local law enforcement and the State Agency on 9/21/23 and 1/7/24. Cross reference F610 for failure to investigate an alleged violation

Inspectors wroteBased on record review and interviews, the facility failed to investigate an allegation of abuse for one (#21) of three residents reviewed for abuse out of 23 sample residents. Specifically, the facility failed to ensure two incidents of verbal abuse of unidentified residents by Resident #21 on 9/21/23 and 1/7/24 were thoroughly investigated and documented in a timely manner. Cross-reference F609 for failure to report an alleged violation.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#24) of three residents reviewed for pressure ulcers out of 23 sample residents received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure Resident #24 did not experience a worsening of a shear/friction injury, which the resident was readmitted to the facility with, to an unstageable pressure injury.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the environment remained as free of accident hazards as is possible, and ensure each resident received adequate supervision for six residents who resided on the secure unit out of 23 sample residents. Specifically, the facility failed to ensure Resident #59's private sitter, who was hired by the resident's family, did not provide assistance to other residents who resided on the secure unit.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure two (#60 and #24) of three residents reviewed for unnecessary medications out of 23 sample residents were as free from unnecessary drugs as possible. Specifically, the facility failed to: -Ensure Resident #60 and Resident #24 were adequately monitored and documented side effects of anticoagulant medication; and, -Establish pain parameters for pain medications for Resident #24.

Inspectors wroteC. Resident #15 1. Resident status Resident #45, under age [AGE], was admitted on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses include chronic obstructive pulmonary disease (COPD), history of falling, generalized anxiety disorder, cerebral infarction (stroke), unsteadiness on feet, muscle weakness, and difficulty walking. The 9/9/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental health status score of 11 out of 15. According to the MDS assessment the resident required extensive assistance from two people with bed mobility, transfers, toileting and one person assistance with walking in the room, corridor, on and off the unit, personal hygiene, and dressing. [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#60 and #62) of two residents reviewed for catheter care, out of 31 sample residents. Resident #60 admitted to the facility on [DATE] without having a catheter in place. The resident did not have a medical diagnosis to provide clinical indication (reason) for the need for a catheter. While in the care of the facility, the resident fell and fractured a hip and required surgical intervention. The resident returned to the facility on 9/1/22 with the indwelling catheter. The facility failed to ensure Resident #60 had orders for the use of an indwelling catheter to assist the resident with bladder function. [...]

Inspectors wroteBased on observation, document review, and interviews the facility failed to provide a clean, safe, homelike environment for residents on two of three units and in resident common areas. Specifically the facility failed to : -Ensure the privacy curtains were changed on a regular basis; -Ensure the facility was free from urine odors; -Provide clean floors in resident rooms and throughout the facility; -Ensure resident rooms and furnishings were clean, neat, and tidy; -Ensure the heating units in resident rooms were clean and free form dust build up; -Ensure trash cans in resident rooms that contained soiled adult incontinence briefs were emptied timely; -Ensure resident shared medical equipment was in clean condition; -Ensure the shower rooms were cleaned after each use and maintained in good repair free from odors; [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure certified nurse aides (CNAs) were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure CNA staff had completed competencies prior to providing resident care for four (#3, #4, #5 and #6) out of five CNAs reviewed for competencies.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases for two out of three units. Specifically, the facility failed to: -Ensure housekeeping staff cleaned all high-touch surfaces in resident rooms and followed manufacturer surface contact time during routine daily cleaning; -Ensure housekeeping staff followed the appropriate procedure when cleaning resident rooms and bathrooms; -Ensure houskeeping staff implemented appropriate hand hygiene with glove changes when moving form handling soiled linens and trash to providing resident care and services; and, -Ensure residents were offered hand hygiene prior to eating meals. [...]

Inspectors wroteBased on record review and interviews, the facility failed to inform residents of changes in their services covered by Medicare as required, for two (#18 and #23) of three who remained in the facility once services ended, out of 31 sample residents. Specifically, the facility failed to ensure the residents were fully informed of their rights regarding facility initiated discharges from Medicare part A services. The facility failed to: -Ensure Resident #18 and #23 were fully informed and provided a full description of the type of Medicare part A services that were ending, give the estimated cost of services should the resident choose to pay out of pocket to continue services, and the reason why Medicare would not continue to pay for the particular service, should the resident decided to appeal the direction; [...]

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to maintain privacy for one (#62) one of two residents reviewed for privacy out of 31 sample residents. Specifically, the facility failed to ensure Resident #62 received privacy during personal care.

Inspectors wroteBased on record review and staff interviews, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program for two (#15 and #43) of two residents reviewed for PASRR compliance out of 31 sample residents. Specifically the facility failed to include PASRR level II in the resident's medical record for Resident #15 and PASRR Level I or II for resident #43.