St. Frances Nsg & Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to ensure their grievance policy and procedure was followed for 1 (Resident #20) of 1 resident reviewed for missing personal property. The facility failed to initiate a grievance for Resident #20 regarding the reported missing money. Total sample size was 47.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain grooming for 1 (Resident #64) of 3 residents reviewed for ADL care. The total sample size was 47. Review of facility undated policy titled, Activities of Daily Living (ADLs) revealed in part. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident #64's medical record revealed an admission date of 09/26/1986, with diagnoses that included, in part. Unspecified Vision Loss, Unspecified Intellectual Disabilities, and Communication Deficit. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the planned menus were followed to meet the nutritional needs of the residents that required mechanically altered diets. The facility failed to provide bread or bread substitute for 2 (#68 and #69) of 2 residents who received mechanically altered diets.

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety by failing to ensure open food items stored in the pantry and refrigerator were properly sealed and labeled with an open date. This deficient practice had the potential to affect all 44 residents who received meals served from the kitchen.

Inspectors wroteBased on record review and an interview, the facility failed to ensure a resident's medical record was accurately documented in accordance with accepted professional standards and practices. The facility failed to ensure activities of daily living tasks performed for Resident #2 were accurately documented in the resident's medical record.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received mail on Saturdays. This has the potential to affect all 73 residents residing in the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure residents were free of any significant medication errors for 1 (#29) of 3 (#1, #23, and #29) Residents observed during medication administration, by failing to administer Spironolactone (antihypertensive) medication as ordered. Review of the facility's undated policy titled Medications- Administering on 04/30/2025 at 11:31 a.m. read in part . Medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Observation on 04/29/2025 at 7:54 a.m. revealed S12 LPN performed medication administration for Resident #29. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident # 22) of 4 (Resident #9, Resident #22, Resident #43, and Resident #225) sampled Residents reviewed for dignity in a total sample size of 25. The facility failed to ensure S7 CNA did not stand while feeding Resident #22 during meal service.

Inspectors wroteBased on record review and interview the facility failed to ensure an allegation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#74) of 25 Sampled Residents.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #9) resident of 25 sampled residents. The facility failed to ensure Resident #9's care plan for Psychotropic drugs: Risperdal, Buspirone, and Trazodone was developed and/or initiated.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure Physician's Orders were implemented. The facility failed to ensure supplements were administered as ordered for 1 (Resident #22). Total sample 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident received adequate supervision to prevent incidents and accidents. The facility failed to ensure a resident received supervision while smoking for 1 (Resident #178) of 1 resident reviewed for smoking.

Inspectors wroteBased on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #4) of 1 sampled residents reviewed for respiratory care. The facility failed to ensure equipment was properly changed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5%. The facility failed to: 1. Follow the manufacturer's instructions of Do Not Crush for a medication administered to Resident #23; and 2. Administer a medication as ordered for Resident #29. A total of 36 opportunities were observed for the 3 Residents (#1, #23, and #29) observed during medication administration, which included 2 medication errors for a medication error rate of 5.56%.

Inspectors wroteBased on interview and record review, the facility failed to include the Medical Director or his designee and Director of Nursing in the Quality Assessment and Assurance (QAA) committee quarterly meeting, as required. The facility's total census was 73.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection for 2 (Resident #7 and Resident #22) sampled residents by failing to: 1. Ensure staff wore PPE for Resident #7 who was on Enhanced Barrier Precautions; and 2. Ensure staff did not blow on Resident #22's food to cool it while feeding her.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #2, who had been assessed to be at high risk for elopement, received adequate supervision to prevent the resident from eloping from the facility, for 1 (#2) of 4 (#1, #2, #3, and #4) residents reviewed for elopement.

Inspectors wroteBased on interview on record review, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 (#2) of 4 (#1, #2, #3, and #4) residents reviewed for elopement. The Administration failed to have an effective system in place to respond when Resident #2, who was assessed to be at risk for elopement, eloped from the facility on 10/26/2024 at 1:55 a.m. The likelihood continued for the remaining 3 residents (#1, #3 and #4), who were assessed as being at risk for elopement. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure an injury of unknown source was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#1) of 4 (#1, #2, #3, and #4) sampled residents reviewed for abuse.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored and labeled properly in accordance with currently accepted professional principles on 1 (Hall A) of 2 (Hall A and Hall B) medication carts and 1 of 1 medication storage rooms.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for 28 residents that received mechanically altered diets prepared by the facility kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 5 (Resident #30, Resident #35, Resident #40, Resident #61 and Resident #119) of 5 Residents who were ordered and served pureed diets.

Inspectors wroteBased on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to: 1) store dishes and utensils under sanitary conditions; 2) ensure food preparation equipment was clean. This deficient practice had the potential to affect the 64 residents that received meals prepared in the kitchen.

Inspectors wroteBased on interview and record review the facility failed to ensure that the resident's person centered plan of care for malnutrition was followed for 1 (#5) of 26 sampled residents by failing to: 1. Identify and report significant weight loss to Resident #5's physician and RP (Responsible Party), 2. Request an RD (Registered Dietician) consult, 3. Have RD assess Resident #5 at least annually, and 4. Perform a Weight Change Evaluation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide oral care to dependent resident for 1 (Resident #61) of 26 sample size residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #9) of 1 residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly stored.

Inspectors wroteBased on record review and interview, the facility failed to comply with the requirement of yearly in-service training for CNAs. The facility failed to provide documentation for the required 12 hours of training which included dementia management and abuse prevention trainings for 2 (S11 CNA and S13 CNA) of 5 (S9 CNA, S11 CNA, S12 CNA, S13 CNA, and S14 CNA) CNA personnel records reviewed.