St. Francis Rehabilitation & Nursing Center

Inspectors wroteBased on observations and interviews, the facility failed to adhere to infection control standards of practice to prevent contamination and the spread of infection for three Residents (#33, #89, #78) out of a total sample of 24 residents. Specifically,1) for Resident #33, the facility failed to ensure that nursing staff performed hand hygiene as required during glove changes while providing wound care.2) for Resident #89, the facility failed to ensure that appropriate Personal Protective Equipment (PPE: items such as gowns and gloves worn to prevent the spread of infection) was worn as required when nursing staff failed to don gowns while providing high-contact care for the Resident with a Physician's order for Enhanced Barrier Precautions (EBP).3) for Resident #78, the facility failed to: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#74) of two applicable residents who require hemodialysis, and have a Central Venous Catheter (CVC - a flexible tube inserted into a large vein in the chest for exchanging blood between a patient and a hemodialysis machine), out of a total sample of 24 residents. Specifically, for Resident #74, the facility failed to ensure that an emergency kit including a non-toothed clamp was always available at the Resident's bedside as ordered by the Physician, when a CVC catheter was in use, for the management of dialysis emergencies related to the CVC catheter.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired and had a history of wandering in his/her wheelchair, the Facility failed to ensure he/she was free from physical abuse by a staff member, when on 07/19/25, Certified Nurse Aide (CNA) #1, after seeing Resident #1 exiting another resident's room with an object in his/her hands, that did not belong to him/her, CNA #1 slapped his/her hand and grabbed the object away from him/her, all of which was captured on video by a visitor.

Inspectors wroteBased on observation, interview and policy review, the facility failed to provide a dignified dining experience for one Resident (#97) out of total sample of 24 residents. Specifically, the facility staff remained standing while assisting Resident #97 during a breakfast meal.

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to provide ongoing review of residents rights and services to residents during the residents stay, for six Residents who attended Resident Council. Specifically, the facility failed to conduct ongoing review of resident's rights and services with six Residents who attended monthly Resident Council meetings in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean, safe, comfortable, and homelike environment for one Resident (#21) out of a total sample of 24 residents. Specifically, the facility failed to ensure that Resident #21's wheelchair was provided with preventative and routine maintenance and maintained in a clean, safe and homelike condition.

Inspectors wroteBased on interview, record and policy review, the facility failed to develop a comprehensive care plan for the use of anticoagulant (also known as blood thinner: used to prevent or treat blood clots in blood vessels and the heart) and antiplatelet (prevents platelets from sticking together and decreasing the body's ability to form blood clots) medications for two Residents (#8 and #78), out of a total sample of 24 residents. Specifically, the facility failed to: 1) develop a care plan for Resident #8 for Clopidogrel Bisulfate (Plavix: antiplatelet medication) that addressed the risks, potential side effects, and monitoring associated with the use of the medication. 2) develop a care plan for Resident #78 for Apixaban (Eliquis: anticoagulant medication) that addressed the risks, potential side effects, and monitoring associated with the use of the medication.

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to ensure that activities of daily living (ADL's- activities related to personal care which include bathing, dressing, grooming, and eating) were provided for one Resident (#316), out of a total sample of 24 residents. Specifically, the facility failed to ensure that personal care relative to grooming was provided for Resident #316 who required the assistance of staff for care.

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#48), out of a total sample of 24 residents. Specifically, the facility failed to ensure that Resident #48's oxygen concentrator (a medical device used to deliver supplemental oxygen) was maintained in a clean and sanitary manner to prevent contamination, the spread of infection and device malfunction when dust and debris was not being approppriately cleaned from the top rear air intake vent of the device.

Inspectors wroteBased on record review and interview, the facility failed to ensure that COVID-19 vaccination was offered and administered, according to professional standards, for two Residents (#101 and #100) out of five applicable residents, in a total sample of 24 residents. Specifically, the facility staff failed to: 1. offer the COVID-19 vaccine to Resident #101 when the Resident had received previous doses of the COVID-19 vaccine, the COVID-19 vaccine was not medically contraindicated for the Resident, and the Resident was not up to date with his/her COVID-19 vaccinations. 2. administer the COVID-19 vaccine to Resident #100 when the Resident had received previous doses of the COVID-19 vaccine, was not up to date with the COVID-19 vaccine and the Resident's Healthcare Proxy (HCP: [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of adaptive equipment (a double handled mug) for beverages due to hand tremors, as well as staff assistance with set-up for meals, the Facility failed to ensure he/she received adequate staff assistance during meal service related to the nurses' inspection of meal trays for appropriateness of the meal, as well as for the inclusion of necessary adaptive equipment per each resident's meal ticket, prior to the meal tray being delivered and served to the resident, in an effort to prevent an incident/accident resulting in an injury. On 03/30/24, Resident #1's dinner tray was not checked by nursing prior to being served as required, the tray did not include his/her required double handled mug and his/her hot beverage was served in a Styrofoam cup. [...]

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), whose Advanced Directives and Physician's Order indicated his/her elected code status was Do Not Resuscitate (DNR, medical order written by a physician, which instructs healthcare providers not to do cardiopulmonary resuscitation, in the event of cardiac or respiratory arrest) the Facility failed to ensure nursing staff honored his/her right to self-determination related to his/her choice of Advanced Directives. On [DATE], at approximately 8:30 A.M., Resident #1 was found unresponsive, was assessed by nursing to be without a pulse or respirations, and without verifying his/her code status, nursing staff immediately intervened and initiated life saving measures including starting chest compressions for CPR and activating the 911. [...]

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), whose Comprehensive Person Centered Plan of Care indicated staff were to honor his/her Advance Directives, which indicated he/she was a Do Not Resuscitate (DNR, medical order written by a physician, it instructs healthcare providers not to do cardiopulmonary resuscitation in the event of cardiac or respiratory arrest), the Facility failed to ensure the staff implemented and followed interventions identified in his/her plan of care related to his/her Advanced Directives, when on [DATE], at approximately 8:30 A.M., after being found unresponsive, and assessed by nursing to be without a pulse or respirations, nursing staff immediately intervened and initiated Cardiopulmonary Resuscitation (CPR) in an attempt to resuscitate him/her, and activated the 911, without first verifying his/her code status. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Advanced Directives indicated he/she was a Do Not Resuscitate (DNR, medical order written by a physician, it instructs healthcare providers not to do cardiopulmonary resuscitation in the event of cardiac or respiratory arrest), the Facility failed to ensure services provided by nursing met professional standards of practice, when nursing initiated life saving measures including performing Cardiopulmonary Resuscitation on a resident who was a DNR. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), who on [DATE] was found unresponsive and for whom nursing staff initiated life saving measures (initiated cardiopulmonary resuscitation by administering chest compressions), the Facility failed to ensure they maintained a complete and accurate medical record when there was no nursing documentation in Resident #1's Medical Record related to the administration of chest compressions.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff notified the Physician/Non-Physician Practitioner (NPP: a Nurse Practitioner, clinical Nurse Specialist, or Physician Assistant) of the unavailability and multiple missed doses of an ordered medication for one Resident (#4) out of 25 total sampled residents. Specifically, the facility failed to notify the Physician/NPP when ordered doses of Fondaparinux Sodium Solution (injectable blood thinning medication used to treat and prevent blood clots) were unavailable and not administered to Resident #4 as ordered, for a documented history of Deep Vein Thrombosis (DVT- a blood clot located in a deep vein) and chronic Pulmonary Embolism (PE- a condition where one or more arteries in the lungs becomes blocked by a blood clot), increasing his/her risk for development of blood clots.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure its staff provided appropriate care and services for three Residents (#88, #77, and #114), who required an indwelling urinary catheter (a tube placed through the urethra into the bladder to drain urine), out of a total sample of 25 residents. Specifically, the facility staff failed to ensure that the indwelling urinary catheter tubings for Residents #88, #77, and #114 were securely placed as required to prevent possible dislodgement and trauma.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (#27) out of a total sample of 25 residents, was free from unnecessary medications. Specifically, facility staff administered prophylactic (intended to prevent disease) antibiotic medication treatment to Resident #27 for seven consecutive days to prepare the Resident for a dental procedure that did not occur.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident (#4) out of 25 total sampled residents,was free of significant medication errors. Specifically, facility staff failed to implement necessary action when daily administration of Fondaparinux Sodium Solution was: a) ordered by the Physician/NPP, and b) omitted from the Resident's medication administration for three consecutive days in January 2023, two consecutive days and one non-consecutive day in February 2023, when the Resident had a documented history of a DVT and chronic PE, increasing his/her risk for development of blood clots.

Inspectors wroteBased on record review and interview the facility failed to ensure that its staff implemented the plan of care for one Resident (#114) out of a total sample of 25 residents. Specifically, the facility failed to complete weekly weights for the Resident as indicated in the care plan.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff provided adequate care and services related to vision for one Resident (#51) out of a total sample of 25 residents. Specifically, the facility staff failed to follow the recommendations of an Optometrist for a follow up vision appointment and treatment for Resident #51.

Inspectors wroteBased on observation, interview, and record review, the facility failed to schedule a follow-up dental appointment for one Resident (#27) out of a total sample of 25 residents. Specifically, facility staff failed to schedule a dental appointment for Resident #27 to have two teeth extracted after the Resident was assessed by the Dental Consultant, extractions were recommended, and consent had been obtained for the procedure.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to maintain adequate infection control practices in the laundry area to prevent cross contamination. Specifically, the facility failed to ensure its staff: 1) kept soiled linens in a bag prior to putting them down a laundry chute, and 2) kept clean items out of the soiled laundry area.