St. Andrew's at Francis Place

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) D, an agency CNA, respected Resident #24's right to remain in bed. On 10/2/25, the CNA transferred the resident out of bed for a shower after the resident told the CNA he/she did not want to get out of bed. The resident said he/she was upset about being made to get up, the transfer was rough and felt like a tussle. During the transfer, the resident sustained a large skin tear, approximately ten centimeters (cm) long, to the left lower leg. The resident was sent to the hospital where five sutures were required to close the skin tear. The facility investigated the incident and in-serviced some nursing staff on transfer training. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents designated to receive walk to dine restorative services (staff assist residents to walk to and/or from the dining room daily at breakfast, lunch or dinner) received that restorative service. The facility identified 22 residents on the walk to dine program. Of those 22, five were interviewable and all five said staff did not walk them to and/or from the dining room for any of the three meals (Residents #18, #9, #21, #2 and #19). The census was 101. Review of the facility's Restorative Nursing Care policy dated 2021, showed:Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's needs and preferences were accommodated when staff rearranged two resident's rooms which prevented one resident access to some of his/her personal belongings (Resident #64) and hindered one resident from freely maneuvering his/her wheelchair in between his/her side of the bed and the other bed in the room (Resident #46). In addition, after removing all side rails in the facility, the facility failed to provide alternative options for four residents who requested the use of siderails for mobility and repositioning (Residents #13, #46, #12 and #14). The sample was 18. The census was 73. Review of the facility's Resident Rights policy, dated 9/19/24, showed: -Procedure: staff competencies in resident rights information will include the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a consistent and updated code status (a medical directive that specifies the type of resuscitation and medical interventions a resident wishes to receive in the event of a cardiac or respiratory arrest) in the residents' medical records for four out of 18 sampled residents (Residents #18, # 14, #17 and #62). The census was 73. Review of the facility's Therapeutic Support Level/Resuscitation Plan Policy, dated revised 2/2010, showed: -In order to facilitate timely intervention in those situations which require immediate action, and to support the resident's wishes related to health care directives, the resident or their legally appointed representative or healthcare agent, upon admission to the facility, will be asked to complete a therapeutic support level/resuscitation plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that kitchen equipment was kept clean during five of six days of observation. In addition, the facility failed to ensure expired thickened milk was discarded. This had the potential to affect all residents who consumed food from the facility kitchen. The census was 73. Review of the kitchen's cleaning schedules, showed: -November 2024's schedule: -Steamer cleaned: 11/11/24; -Stove (trays) cleaned: 11/3/24, 11/14/24 and 11/20/24; -Flat grill cleaned: Not listed on cleaning schedule; -Deep fryer cleaned: 11/6/24, 11/11/24 and 11/22/24; -January 2025's schedule: -Steamer cleaned: no days initialed; -Stove (trays) cleaned: 1/9/25 and 1/22/25; -Flat grill cleaned: Not listed on cleaning schedule; -Deep fryer cleaned: 1/2/25 and 1/14/25; -No cleaning schedule for December 2024. 1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure they had a system in place to track the required Certified Nurse Aide (CNA) 12 hours annual education (in-services). The facility identified 12 CNAs who worked for the facility for at least one year. Six CNAs (CNA #B, #D, #E, #G, #H, and #I) and Four Certified Medication Technician (CMT)s (CMT #A, #C, #F and #J) were sampled. The facility failed to document the length of time the training was provided for all sampled staff . The census was 73. 1. Review of CNA B's employee file showed: -Date of hire: 10/17/22; -Three in-services were completed; -The in-services failed to show the length of time the training was provided. 2. Review of CNA D's employee file, showed: -Date of hire: 10/10/22; -10 in-services were completed; -The in-services failed to show the length of time the training was provided. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were followed up on for the final accounting within 30 days for a resident who expired. This affected one of five residents who expired and had money in their resident trust account (Residents #240). The census was 73. Review of Resident #240's resident fund account, showed the following: -Resident expired on [DATE]; -A balance of $481.39; -TPL completed [DATE]; -As of [DATE], the resident's account remained open with a balance of $481.39. During an interview on [DATE] at 11:10 A.M., the Corporate Business Office Manager (BOM) said the resident expired on [DATE]. The balance report was submitted on [DATE]. The balance was $481.39. She was still awaiting a letter to close account. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise care plans to address a recent fall and hospice status for two of 18 sampled residents (Residents #26 and #56). The census was 73. Review of the facility's Care Plan policy dated January 2011 and reviewed January 2023 showed: -Policy: It is the policy of the facility to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, nutritional, emotional, spiritual, and psychological needs. -Procedures: -An interdisciplinary team, in coordination with the resident and his/her responsible party, develops and maintains a comprehensive care plan for each resident; -The comprehensive care plan has been designed to: -Incorporate identified problem's areas; -Incorporate risk factors associated with identified problems; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure care was provided in accordance with professional standards of practice by not following the physician orders for daily and weekly weights for one resident (Resident #78), and not obtaining physician's order for hospice care for one resident (Resident #18). The sample was 18. The census was 73. Review of the facility's Physicians' Orders policy, dated 1/2011, showed: -Policy: All treatments and medications must be ordered by the resident's attending physician; -Procedure: All physicians' orders shall be recorded on the Physician's Order Form for each resident and must be signed or initialed by the attending/prescribing physician as per state and/or federal regulations and as outlined in the facility's Management Services Corporate Compliance Manual; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a 14-day stop date for the PRN (as needed) use of psychotropic medications or provide a rationale for the continued use of the medication for two residents (Residents #18 and #15). The facility census was 73. Review of the facility's undated Psychotropic Medication Use policy, showed: -Policy: Based upon each resident's comprehensive assessment, the facility will ensure that residents who have not used psychotropic drugs are not given them unless the medication is necessary to treat a specific condition that is diagnosed and documented in the clinical record. Residents will not receive psychotropic medications unless behavioral programming and/or environmental changes or other non-pharmacological interventions have failed to sufficiently address the resident's target behavioral goals; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident records were complete and accurately documented when staff failed to document one resident's treatments (Residents #26). In addition, the facility failed to have the certification of terminal illness for one resident (resident #56) who was receiving hospice services. The sample was 18. The census was 73. Review of the facility's Administration Procedures for all Medications policy, dated May 2018, showed: -After administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the Medication Administration Record (MAR) or the Treatment Administration Record (TAR); -If resident refuses medication, document refusal on MAR or TAR; -Notification of physician/prescriber for persistent refusals. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards when staff failed to wear appropriate Personal Protective Equipment (PPE) for two residents (Resident #26 and #20) and failed to post signage for one resident (Resident #18) who required Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS). [...]

Inspectors wroteSee the deficiency F550 cited at Event Id DXDQ12. Based on interview and record review, the facility failed to treat each resident with respect and dignity, when they failed to ensure one resident was assisted by female staff after he/she expressed his/her preference (Resident #7). The sample size was seven. The census was 90. The administrator was notified on 10/30/24, of the past non-compliance. The facility updated the resident's care plan regarding caregiver preferences and the resident was assigned female staff for direct care. Staff are knowledgeable of the resident's wishes and follow the staffing assignments. The deficiency was corrected on 9/27/24. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/18/24, showed: -Cognitively intact; [...]

Inspectors wroteSee the deficiency F684 cited at Event Id DXDQ12. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 9/19/24. Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one resident with a skin tear (Resident #9) when, on 10/30/24, the resident had a dressing on his/her left elbow that was dated 10/22/24. The skin under the dressing had a large black scab over the 4 steri strips (thin, adhesive strips that help close minor cuts and wounds while they heal) that had been placed on the open area without a physician's order. The sample size was 7. The census was 90. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/11/24, showed: [...]

Inspectors wroteSee the deficiency F689 cited at Event Id DXDQ12. Based on observation, interview and record review, the facility failed to follow their fall policy when the facility failed to assess and complete neurological checks as indicated per facility policy and implement fall interventions as indicated on the plan of care, for three residents (Residents #2, #9, and #8). The sample size was 7. The census was 90. Review of the facility's Fall Risk Reduction policy, revised 2/2019, showed: -Purpose: -To identify residents at risk for falls and implement the interventions to reduce risks; -To ensure appropriate and prompt follow up of resident falls to reduce risk of further falls; -To measure effectiveness of fall reduction interventions; -Procedure: -Residents will be assessed for fall risk at the time of admission/re-admission; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one resident with a gastronomy tube (g-tube, a tube placed through the abdomen into the stomach to provide nutrition, hydration and medication) (Resident #3) and one resident with a Suprapubic catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine) (Resident #1). The facility also failed to ensure additional ordered skin treatments were completed for these two residents and four other residents sampled (Residents #2, #4, #5 and #6). The sample size was 6. The census was 88. 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Moderate cognitive impairment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their fall policy when the facility failed to assess and complete neurological checks as indicated per facility policy and implement fall interventions as indicated on the plan of care, for three residents (Residents #2, #9, and #8). The sample size was 7. The census was 90. Review of the facility's Fall Risk Reduction policy, revised 2/2019, showed: -Purpose: -To identify residents at risk for falls and implement the interventions to reduce risks; -To ensure appropriate and prompt follow up of resident falls to reduce risk of further falls; -To measure effectiveness of fall reduction interventions; -Procedure: -Residents will be assessed for fall risk at the time of admission/re-admission; [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation/diversion (the unauthorized removal) of controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) for 11 residents (Residents #11, #14, #15, #16, #17, #18, #13, #10, #19, #12 and #20) who resided on both the Northeast and Southwest side of the facility. The census was 103. Review of the facility's Resident Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, revised date 1/2017, showed: -Policy: The facility affirms the right of our residents to be free from verbal, sexual, physical, mental abuse, neglect, misappropriation of resident property, crime, corporal punishment, exploitation and/or involuntary seclusion. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving misappropriation/diversion (the unauthorized removal) of controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) were reported within twenty-four hours to the Department of Health and Senior Services (DHSS), law enforcement, and the Board of Nursing after the facility was made aware of allegations of diversion for 11 residents (Residents #11, #14, #15, #16, #17, #18, #13, #10, #19, #12 and #20) by two nurses, Licensed Practical Nurse (LPN) C and LPN D on the morning of 1/22/24. The census was 103. Review of the facility's Resident Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, revised date 1/2017, showed: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent further misappropriation/diversion (the unauthorized removal) of controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) by not following the facility's policy for suspension during an investigation. Licensed Practical Nurse (LPN) C and LPN D reported alleged violations of misappropriation/diversion by LPN B on the morning of 1/22/24. The facility allowed LPN B to continue working on 1/22/24, 1/23/24, and 1/24/24, while the facility investigated the allegation. LPN B continued the misappropriation/diversion with nine residents (Resident #11, #15, #16, #17, #18, #13, #19, #12 and #20) during the three days LPN B was not suspended. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow a Nurse Practitioner's (NP) order of a stat (immediate) x-ray of a resident's right shoulder and right humerus (upper arm bone) after the resident had a fall while ambulating with his/her rollater walker (Resident #2). In addition, the facility failed to document the incident of the resident's fall in his/her medical record and failed to investigate the fall. The sample size was 20. The census was 103. Review of the facility's Fall Risk Reduction, review dated 2/2019, showed the following: -Purpose: To identify residents at risk for falls and implement interventions to reduce risks, to ensure appropriate and prompt follow up of resident falls to·reduce risk of further falls and to measure effectiveness of fall reduction interventions; -Actions Steps Following a Fall: -First be sure that the resident is safe; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide two person care in accordance with the care plan, during perineal (the areas between and including the hips, to include the anal and genital areas) care which resulted in a resident rolling out of bed onto the floor for one of 20 sampled residents (Resident #1). The census was 103. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/5/24, showed the following: -Moderate cognitive impairment; -No moods or behaviors; -Impairment of lower extremities on both sides; -Dependent for toileting hygiene, helper must do everything; -Dependent for rolling left to right; -Diagnoses of multiple sclerosis (MS, a potentially disabling disease of the brain and spinal cord) and depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow acceptable standards of practice when staff checked resident's blood sugar levels without a physician order's and failed to ensure orders for insulin included parameters for when to notify the physician when blood sugar levels were outside of acceptable parameters, for thee of three residents sampled for insulin administration (Resident #76, #69, and #25). The census was 101. Review of the facility's Physician's Orders policy, dated 2/22, showed: -This community will follow physician's order except where the order is clearly poor practice, erroneous, or ethically unsound as a practical matter; -Physician's orders will be entered into the electronic medical record (EMR) as soon as practicable once received from the physician; -Orders will be carried out as per the physician. [...]

Inspectors wroteBased on interview and record review, the facility the facility failed to provide residents with a transfer notice when transferred to the hospital, for two of two residents investigated for hospital transfers (Resident #76 and #301). The Census was 101. Review of the facility's Transfer and Discharge from the Facility policy, dated 2017, showed: -It is the policy of this facility that each resident has the right to remain in the facility and not transfer or discharge a resident unless a transfer or discharge from the facility is: Necessary for the resident's welfare and the resident's needs cannot be met in the facility; -Before a facility transfer or discharges a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with a mental health disorder and/or individuals with intellectual disabilities had a DA-124 Level One Screen (used to evaluate for the presence of psychiatric conditions to determine if a Preadmission Screening/Annual Resident Review (PASARR) Level Two Screen was required), as required for two of 21 sampled residents (Residents #23 and #80). The census was 101. Review of the facility's undated PASARR policy and procedure, showed: -The facility promotes and supports a resident centered approach to care. The purpose of this policy is to define and set expectations regarding the appropriate preadmission assessment of all individuals with a mental disorder and individuals with intellectual disability; [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to The Centers of Medicare and Medicaid services (CMS) complete and accurate direct care staffing information no less frequently than quarterly, for the quarter immediately preceding the annual survey. The census was 101. Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report, for fiscal year quarter 3, 2023 (April 1 through June 30, 2023), showed the facility triggered for failing to submit data for the quarter. During an interview on 10/10/23 at 5:17 P.M., the Administrator said the Senior Director of Human Resources is responsible for submitting PBJ information. During email communication on 10/10/23 at 6:18 P.M., the Senior Director of Human Resources said last quarters PBJ submission was missed by a day, and she could not submit it.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to obtain physician's orders for the administration of oxygen and failed to complete weekly skin assessments as ordered (Residents #77 and #72). The sample size was 18. The facility census was 90. 1. Review of the facility's oxygen policy, updated February 2019, showed facility must have a physician's order to apply oxygen. Oxygen may be administered in an emergency until a physician's order can be obtained. Review Resident #77's significant change Minimum Data Set (MDS), a federally mandates assessment instrument completed by facility staff, dated 9/18/20, showed: -Severely impaired cognition; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed (PRN) psychiatric medications were re-evaluated after 14 days of use for one of five residents reviewed for unnecessary psychotropic medications (Resident #23). The sample was 18. The census was 90. Review of the facility's policy on antipsychotics, dated March 2020, showed PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Review of Resident #23's significant change Minimum Data Set (MDS), a federally mandated assessment instrument used by facility staff, dated 8/5/20, showed: -Brief Interview of Mental Status (BIMS) score of 0 out of 15; -A BIMS score of 0 showed severe cognitive impairment; [...]

Inspectors wroteBased on observation and interview, the facility failed ensure the ice machine had an air gap, to prevent backflow from the drain pipe into the ice machine, potentially contaminating the contents of the ice machine. The census was 90. Observation and interview on 10/21/20 at 9:13 A.M., showed the ice machine drain tubing extended down from the ice machine and hung at an angle, with the lower end of the drain tubing at the level of the drain pipe. The dietary manager (DM) said maintenance just cleaned the ice machine a week ago, and the drain might have been moved then. During an interview on 10/21/20 at 9:16 A.M. the maintenance director said they did clean the ice machine last week. The ice machine's drain pipe should be higher than the drain, at a 45 degree angle, and at least an inch or so above the drain. [...]