Mount St. Francis Nursing Center

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for three of three certified nurse aides (CNA). Specifically, the facility to complete regular in-service education based on the outcome of the annual performance reviews for CNA #8, CNA #9 and CNA #10.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#16) of two residents reviewed for abuse out of 46 sample residents was free from abuse. Specially, the facility failed to protect Resident #16 from sexual abuse by Resident #58.

Inspectors wroteBased on interviews and record review, the facility failed to initiate an appropriate facility-initiated discharge for one (#58) of three residents reviewed for appropriate discharge out of 32 sample residents. Specifically, the facility failed to: -Complete an assessment with attempted interventions prior to giving the resident a discharge notice; and, -Ensure there was a documented basis from the physician that the resident's needs could not be met and discharge was necessary.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper storage of medications in one of three medication storage rooms and three of three medication storage carts. Specifically, the facility failed to: -Ensure medications were labeled with the date they were opened; and, -Ensure expired or discontinued medications were removed and discarded from medication carts and storage refrigerators.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment for residents to help prevent the development and transmission of diseases and infection on one of three units. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) for Resident #20, who was on enhanced barrier precautions (EBP); -Ensure proper infection control practices were followed during wound care; and, -Ensure hand hygiene was performed appropriately during wound care.

Inspectors wroteBased on interviews and record review, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified ICP involved with the facility's infection prevention and control program.

Inspectors wroteBased on observations and interviews, 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 diseases and infection for one of three floors. Specifically, the facility failed to: -Ensure proper personal protective equipment (PPE) was utilized in COVID-19 positive rooms; -Ensure residents were provided with an opportunity to participate in hand hygiene before meals; -Ensure shared equipment was properly disinfected between use; -Ensure staff followed proper hand hygiene procedures when moving from task to task; and, -Provide accurate isolation precautions, including isolation signage and assure the resident doors remained closed.

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner to prevent food-borne illness. Specifically, the facility failed to ensure: -Holding temperatures were appropriate; -Moisture was not between stacked pans; -Appropriate sanitation of utensils, lids and thermometers; and, -Appropriate sanitation of food coolers on resident floors.

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture, appearance and temperature.

Inspectors wroteBased on observations, record review and interviews; the facility failed to provide each resident with a nourishing, well balanced diet that meets his or her nutritional and special dietary needs, taking into consideration the allegations and preferences of each resident for four (#71, #209, #91 and #53) out of 48 sample residents. Specifically, the facility failed to ensure Residents #71, #209, #91 and #53 were provided food that accommodated their food dislikes and preferences.

Inspectors wroteBased on observations and interviews, 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 diseases and infection for two out of three units at the facility. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (call lights, door handles and hand rails); -Ensure surface disinfectant times were followed; and, -Ensure staff engaged in hand hygiene between providing care to two residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#36) out of 48 sample residents had the right to receive visitors of their choosing at the time of their choosing. Specifically, the facility failed to ensure Resident #36 was able to visit with a visitor of her choice.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure five (#2, #4, #7, #27 and #43) of six residents reviewed for abuse out of 48 sample residents were kept free from abuse. Specifically, the facility failed to ensure Residents #2, #4, #7, #27 and #43 were kept free from abuse by Resident #92.

Inspectors wroteBased on record review and interviews, the facility failed to provide two (#86 and #45) of two residents out of 48 sample residents with the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. Specifically, the facility failed to: -Ensure resident #86 received showers according to her preferences; and, -Ensure resident #45 was provided with a functional system to meet her communication needs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#158) residents out of two who required respiratory care received the care consistent with professional standards of practice out of 48 sample residents. Specifically, the facility failed to for Resident #158: -Ensure a physician's order was in place to include the appropriate care of a continuous positive airway pressure (CPAP) machine; -Follow manufacturer recommendations to maintain, clean, sanitize, and store Resident #158's CPAP; -Accurately complete section O in the comprehensive minimum data set (MDS) assessment under respiratory treatments; -Ensure a care plan was in place to include settings, cleaning, disinfecting, and storage of the CPAP; and, -Ensure staff was properly trained to use the CPAP sanitizing chamber. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure nursing staff were able to demonstrate competence in skills and techniques necessary to care for residents who required the use of a continuous positive airway pressure (CPAP) machine as identified in the resident assessment. Specifically, the facility failed to provide training to the nurses on the cleaning, sanitizing and storage of CPAP machines. Cross-reference to F695 respiratory care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#92) of six residents reviewed for dementia care of 48 sample residents received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to comprehensively assess and effectively identify person-centered approaches for dementia care for Resident #92 to prevent resident-to-resident altercations and address repeated behavioral issues which created an environment where abuse persisted.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living (ADLs) for three (#9, #8 and #65) of three residents reviewed out of 32 sample residents. Specifically, the facility failed to: - implement a restorative nursing program as recommended by physical therapy for transfers and range of motion for Resident #9, - implement a restorative nursing program as recommended by physical therapy for range of motion, balance and transfers for Resident #8, and - implement a walk to dine program for resident #65.

Inspectors wroteIII. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the August 2019 computerized physician's orders (CPO), diagnoses included: diabetes mellitus type II, essential hypertension, and atherosclerotic heart disease. The 8/2/19 minimum data set (MDS) assessment documented Resident #9 had no cognitive impairment with a brief interview for mental status score (BIMS) of 14 out of 15. He was totally dependent on staff for bathing and required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. B. Observation On 8/12/19 at approximately 1:45 pm two CNA ' s were observed rolling a mechanical lift into Resident #9's room. C. [...]

Inspectors wroteBased on record review and interviews, the facility failed to meet professional standards of quality for three (# 9, # 74 and #15) of four residents reviewed out of 32 residents sampled. Specifically, the facility failed to: - follow physician's orders to check blood pressure prior to administering Lisinopril (antihypertensive medication) to resident #9, - act on obtaining a physical therapy evaluation timely for Resident #15 as recommended by the medical provider, and - reassess the use of a wander alarm bracelet for Resident #74