The Gardens of St. Francis

Inspectors wroteBased on review of the medical record, staff interview, and policy review the facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects and adverse effects. This affected four (#16, #6, #38, and #68) of five residents reviewed for unnecessary medications. The facility identified 39 residents receiving psychotropic medications. The facility census was 57.

Inspectors wroteBased on medical record reviews, staff interviews, and review of facility policies, the facility failed to ensure pneumococcal and influenza vaccinations were up to date. This affected five (Residents #13, #17, #33, #36, and #56) of five residents reviewed for immunizations. The facility census was 57.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to respect a resident's preference to sleep in. This affected one (#16) of one resident reviewed for sleep preferences. The facility census was 57. Resident #16 admitted to the facility on [DATE] with the diagnosis including, chronic obstructive pulmonary disease, myasthenia gravis, epilepsy, dysphagia, major depression, pseudosarcomatous fibromatosis, hypertension, anxiety disorder, coronary artery disease, insomnia, congestive heart failure, and neurofibromatosis. According to the most current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #16 with moderately impaired cognition, no resistive behaviors, required supervision or touching assistance with eating, dependent for completion of activities of daily living, and utilized a wheelchair for mobility propelled by staff. [...]

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to have a required Preadmission Screening and Resident Review (PASARR) in place prior to admission. This affected one resident, #6, out of four residents reviewed for PASARR. The facility census was 57. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, bipolar disorder, major depressive disorder and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #6, dated 02/04/26, revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive deficits. Further review of the MDS revealed Resident #6 exhibited wandering behaviors one to three days a week. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to apply anti-emboli stockings (TED hose) as ordered by the physician. This affected one resident (#6) out of one reviewed for application of TED hose. The facility census was 57. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbance, muscle wasting and atrophy, generalized osteoarthritis, rheumatic tricuspid insufficiency and cardiomegaly. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #6, dated 02/04/26, revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive deficits. [...]

Inspectors wroteBased on medical record reviews, observations, resident interview, staff interview, and review of facility policy, the facility failed to ensure pressure ulcer prevention measures were utilized. This affected three Residents #3, #33, and #56) of five residents reviewed for pressure ulcers. The facility census was 57.

Inspectors wroteBased on observation, review of late medication reports, staff interview, and policy review, the facility failed to ensure medications administered in a timely manner as ordered. This affected three (Residents #1, #4, and #43) of four residents reviewed for late medications. The facility census was 49.

Inspectors wroteBased on observation, medical record review, hospital document review, staff interview, policy review, and sit-to-stand lift instructions, the facility failed to ensure sufficient fall interventions were put into place to promote resident safety and prevent falls. This resulted in actual harm when Resident #1 fell on [DATE] and sustained a fracture to her right ankle and had a subsequent fall on 01/02/24 and sustained a head laceration which required two staples with no immediate interventions implemented. In addition, the facility failed to ensure transfer equipment was utilized in a safe manner for one (#8) resident. This affected two (#1 and #8) of four residents reviewed for accidents. The facility census was 52. Findings Include: 1. Review of Resident #1's medical record revealed an admission date of 05/03/18. [...]

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure residents were treated with dignity and respect. This affected one (#2) of three residents reviewed for dignity. The facility census was 52. Findings Include: Review of the medical record for Resident #2 revealed an admission date of 07/01/11. Diagnoses included type II diabetes, morbid obesity, Alzheimer's disease, heart failure, peripheral vascular disease, paranoid personality disorder, major depressive disorder, heart failure, and chronic kidney disease. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #2 was cognitively intact. Resident #2 required extensive assistance with bed mobility, transfer, and toilet use. [...]

Inspectors wroteBased on record review, staff interview, and review of the facility guidelines, the facility failed to issue notifications of the ending of skilled Medicare Part A services for residents who remained in the facility. This affected one (#24) of three residents reviewed for liability notices. The facility census was 52. Findings Include: Review of Resident #24's Beneficiary Notice Form revealed Resident #24 began Medicare Part A skilled services on 07/26/23 and Medicare Part A skilled services ended on 09/21/23. The facility initiated the discharge from services and it was noted Resident #24 remained in the facility. There was no indication Resident #24 or her representative were provided a Notice of Medicare Non-Coverage (NOMNC) or an Advanced Beneficiary Notice of Non-Coverage (ABN). Interview on 01/30/24 at 2:08 P.M. [...]

Inspectors wroteBased on observation, medical record review, staff interview, wound treatment management policy, and manufacturer indications for use, the facility failed to ensure skin breakdown treatments were applied as ordered by the physician. This affected one (#19) of one resident reviewed for non-pressure skin impairments. The census was 52.

Inspectors wroteBased on observation, medical record review, staff interview, and a facility catheter care policy, the facility failed to ensure an indwelling urinary catheter was maintained in a manner to prevent infection and care plan interventions were maintained to prevent dislodgement. This affected one (#7) of two residents reviewed for indwelling urinary catheters. The census was 52.

Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure resident pain was effectively managed. This affected one (#23) of two residents reviewed for pain management. The facility census was 52. Findings Include: Review of Resident #23's medical record revealed an admission date of 01/18/22. Diagnoses included major depressive disorder, visual hallucinations, dysphagia, dementia, anxiety disorder, osteoarthritis, adjustment disorder, and pseudobulbar affect. Review of Resident #23's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #23 was rarely or never understood. A Staff Assessment for Mental Status was completed and Resident #23 was assessed with memory problems. [...]

Inspectors wroteBased on observation, resident interview, staff interview, medical record review, and review of facility policy, the facility failed to ensure medications were administered within ordered time frames. This affected one (#203) of two residents reviewed for medications. The facility census was 52. Findings Include: Review of Resident #203's medical record revealed an admission date of 01/19/24. Diagnoses included multiple fractures of right side ribs, respiratory disorder, protein calorie malnutrition, muscle weakness, chronic obstructive pulmonary disease (COPD), and pleurodynia (pain in upper abdomen or chest when breathing). Review of Resident #203's care plan revised 01/23/24 revealed supports and interventions for risk for pain, risk for decline for activities of daily living, behavior of being verbally aggressive, COPD, and desire to return back home. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and facility medication administration policy, the facility failed to ensure medications were administered in accordance with physician orders and within prescribed time frames producing a medication error rate greater than five (5) percent (%). This resulted in three medication errors out of 27 opportunities for a medication error rate of 11.11%. This affected one (#154) of three residents observed for medication administration. The facility census was 52.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and review of the facility policy, the facility to failed to ensure medications were stored in a safe and secure manner. This affected one (#5) of one residents observed for medication storage. The census was 52.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident, family, and staff interview, pharmacy interview, review of pharmacy delivery manifest, review of facility policy, and review of hospital neurology notes, the facility failed to ensure Resident #01 was free of significant medication errors when Resident #01 had not received physician ordered anti-anxiety medication (Klonopin) for three days. Actual Harm occurred to Resident #01 when the facility failed to ensure medications were available for administration resulting in the resident experiencing a seizure attributed to medication withdrawal requiring hospitalization with additional testing, monitoring, and restarting of the ordered medication as a result of the medication error. [...]

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to cover food during hall tray delivery to residents rooms and ensure food was dated properly to prevent food borne illnesses. This had the potential to affect all 53 residents who received food from the kitchen. The facility census was 53.

Inspectors wroteBased on observations, staff interview, review of the facility policy and review of the Centers for Disease Control (CDC) guidance, the facility failed to properly wear facemasks while providing resident care, failed to monitor residents for signs and symptoms of COVID-19 and failed to wear an N95 respirator while performing staff testing for COVID-19 to potentially limit the transmission of COVID-19. This had the potential to affect 53 of 53 residents who reside in the facility. In addition, the facility failed to store oxygen tubing in a sanitary manner, affecting one (#25) resident reviewed for oxygen tube storage. The facility census was 53.

Inspectors wroteBased on medical record review, review of the facility census record for resident COVID-19 testing, staff interview, review of the facility policy, review of staff COVID-19 testing logs, staff laboratory results, and review of guidance from the Centers for Medicare and Medicaid Services (CMS), the facility failed to document resident COVID-19 test results in the electronic medical record (EMR), failed to timely follow up with the laboratory staff COVID-19 test results and failed to monitor a resident who refused COVID-19 testing during a facility outbreak. This had the potential to affect 53 of 53 residents who reside in the facility.

Inspectors wroteBased on observations, resident and staff interview and policy review, the facility failed to maintain a comfortable temperature in the main dining room. This affected seven (#3, #6, #14, #16, #21, #36, and #43) of seven residents observed eating in the main dining room. The facility census was 53.

Inspectors wroteBased on medical record review, observation, staff interview and policy review, the facility failed to develop and/or implement care plan interventions. This affected four (#1, #5, #28 and #49) of 22 residents reviewed for care plans. The facility census was 53.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to implement interventions for positioning, skin conditions, and post fall monitoring. This affected four (#30, #1, #49, and #44) of 22 residents reviewed for care and treatment. The facility census was 53.

Inspectors wroteBased on medical record review, observation, staff interview and review of facility policy, the facility failed to treat residents with dignity. This affected one (#30) resident reviewed for dignity. The facility census was 53.

Inspectors wroteBased on medical record review, observation, resident and staff interview, and review of facility policy, the facility failed to ensure residents choices were honored. This affected one (#13) of three reviewed for choices. The facility census was 53.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to notify the physician or resident representative regarding of resident change in condition involving skin tears, falls and/or resident noncompliance with medical devices. This affected two (#1 and #25) of three residents reviewed for notification. The facility census was 53.

Inspectors wroteBased on medical record review, staff interview, and review of facility's policy, the facility failed to provided written notification of hospital transfer and discharge to the resident, the resident representative, and the ombudsman. This affected two (#204 and #28) of four residents reviewed for transfer and discharge. The facility census was 53.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to provide written notice of the bed hold policy prior to transfer to the hospital. This affected one (#28) of two sampled residents reviewed for hospitalization. The facility census was 53.

Inspectors wroteBased on medical record review and staff interview, the facility failed to accurately reflect resident hospice status in the Minimum Data Set (MDS) assessment. This affected one (#18) of two residents reviewed for accuracy of assessments. The facility census was 53.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure a residents care plan was reviewed and revised when a resident experienced multiple fall. This affected one (#1) out of 22 sampled residents care plans reviewed. The facility census was 53.

Inspectors wroteBased on medical record review observation, staff interview and review of facility policy, the facility failed to provide assistance to a resident who was dependent on staff for eating. This affected one (#18) of two residents reviewed for activities of daily living (ADL's). The facility census was 53.

Inspectors wroteBased on medical record review, observation, resident and staff interview, and review of a facility practice document, the facility failed to ensure residents received annual vision and hearing screenings. This affected two (#24 and #53) of three reviewed for vision and hearing services. The facility census was 53.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to ensure pressure relieving devices were in working condition. This affected one (#53) of three residents reviewed for pressure ulcer care. The facility census was 53.

Inspectors wroteBased on medical record review, observation, staff interview and policy review, the facility failed to ensure fall interventions were in place in accordance with a residents care plan. This affected one (#49) of five residents reviewed for falls. The facility census was 53.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure medications were administered per physician orders. This affected one (#38) of five residents reviewed for unnecessary medications. The facility census was 53.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure resident pharmacy recommendations were addressed in a timely manner by the physician. This affected two (#18 and #13) of five residents reviewed for unnecessary medications. The facility census was 53.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to ensure residents were free from unnecessary medications when the facility failed to ensure as needed (PRN) psychotropic medications were limited to 14 days and renewal evaluation forms were completed for the continuation of use. In addition, the facility failed to ensure supporting diagnosis were included for the use of psychotropic medications. This affected three (#18, #49 and #13) of five residents reviewed for psychotropic medications. The facility census was 53. Findings Include: 1. Review of Resident #13's medical record revealed an admission date of 02/19/21. Diagnoses included Alzheimer's disease, cognitive communication deficit, dysphagia, major depressive disorder, insomnia, anxiety disorder, and dementia. [...]

Inspectors wroteBased on medical record review, observation and resident and staff interview, the facility failed to ensure resident meal preferences were honored and alternates were offered. This affected two (#24 and #48) of eight residents reviewed for food concerns. The facility census was 53.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to maintain accurate medical records documentation regarding residents falls and/or transfer to the hospital. This affected two (#1 and #49) of five sampled residents reviewed for falls. The facility census was 53.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to offer influenza vaccination to residents. This affected one (#53) of five residents reviewed for immunizations. The facility census was 53.