Villa St. Francis Catholic Care Center Inc

Inspectors wroteThe facility identified a census of 136 residents. The facility identified 19 residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure the blood pressure cuff, pulse monitor, and oxygen saturation equipment were sanitized after each resident's use and further failed to ensure all oxygen cannulas and nebulizer masks were stored in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified a census of 136 residents. The sample included 27 residents with four reviewed for pressure ulcers (localized injury to the skin or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R) 66's low air-loss mattress was set to the appropriate weight settings for pressure reduction. This deficient practice placed R66 at risk for complications related to skin breakdown and pressure ulcers.

Inspectors wroteThe facility had a census of 136 residents. The sample included 27 residents, with five residents reviewed for accidents and, or hazards. Based on observation, record review, and interview, the facility failed to secure areas containing hazardous materials to keep them out of reach of 28 cognitively impaired, independently mobile residents. This deficient practice placed the affected residents at risk for preventable injuries and accidents. Findings Included: - On 12/23/24 at 07:10 AM, a walkthrough of the facility was completed with the following observation: An inspection of the 100-unit (secured unit for severely cognitively impaired residents) revealed unlocked closets in the sitting area of the left-side dining room. Both closets contained purple disinfectant wipe containers and tile cleaner spray bottles. [...]

Inspectors wroteThe facility identified a census of 136 residents. The sample included 27 residents with three residents reviewed for dignity. Based on observation, record review, and interviews the facility failed to provide services in a dignified manner for Resident (R) 1 when staff stood over R1 while feeding her a pudding cup. This deficient practice placed R1 at risk for impaired dignity and decreased psychosocial well-being. Findings Included: [...]

Inspectors wroteThe facility identified a census of 136 residents. The sample included 27 residents. Three residents were sampled for reasonable accommodations of resident needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 16's call light was within her reach. This deficient practice left R16 vulnerable to unmet care needs due to the inability to call for staff assistance.

Inspectors wroteThe facility identified a census of 136 residents. The sample included 27 residents with three residents reviewed for Beneficiary Notification. Based on record review and interview the facility failed to ensure a Centers for Medicare and Medicaid Services (CMS) form 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form was provided to Resident (R) 117. This placed R117 at risk of uninformed treatment decisions and unexpected costs.

Inspectors wroteThe facility identified a census of 136 residents. The sample included 27 residents with three residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 1 with grooming and failed to ensure R1's fingernails were cut short and kept clean. This deficient practice placed R1 at risk for impaired dignity, comfort, and further decline in ADL. Findings Included: [...]

Inspectors wroteThe facility identified a census of 136 residents. The sample included 27 residents with five residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1's washcloth was applied to her hands. This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings Included: [...]

Inspectors wroteThe facility identified a census of 136 residents. The sample included 27 residents, with three residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for Resident (R) 66. This deficient practice placed the resident at risk for delayed services and uncommunicated care needs.

Inspectors wroteThe facility had a census of 118 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed to provide food prepared in puree form (to chop or grind into a thick paste), from a standardized recipe for eight residents who received pureed meals which placed the residents at risk to not receive essential nutrients.

Inspectors wroteThe facility had a census 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed store, prepare, and serve food, in a sanitary condition for residents who received meals from the facility kitchen, which placed them at risk for food borne illness.

Inspectors wroteThe facility had a census of 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect for one resident, Resident (R) 69, when another resident urinated on her while in the dining room. This placed R69 at risk for impaired dignity and psychosocial wellbeing.

Inspectors wroteThe facility had a census of 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to provide a comfortable table height while dining for Resident (R) 65. This placed the resident at risk for discomfort and weight loss.

Inspectors wroteThe facility had a census of 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility staff failed to report to administration a resident to resident incident for one sampled resident, Resident (R) 106, who urinated on another resident. This placed the residents at risk for unidentified abuse and/or ongoing mistreatment.

Inspectors wroteThe facility had a census of 118 residents. The sample included 25 residents with two residents reviewed for range of motion difficulties. Based on observation, interview, and record review, the facility failed to provide care and services to maintain range of motion for Resident (R) 61 who had contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in both hands. This deficient practice placed R61 at risk for complications resulting from contracted hands.

Inspectors wroteThe facility had a census of 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 104, who had incontinence, with toileting opportunities in an effort to avoid incontinence and related complications. This placed the resident at risk for skin breakdown and infections.

Inspectors wroteThe facility had a census of 118 residents. The sample included 25 residents, with five reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide the necessary dementia (progressive mental disorder characterized by failing memory, confusion) care and services for Resident (R) 106, who had behaviors of urinating in inappropriate places, grabbing items out of other resident's hands, and wandering. This placed the resident at risk for injury, unmet needs, and imapired quality of life.

Inspectors wroteThe facility identified a census of 150 residents. The sample included 26 residents. Based on observations, record review and interviews the facility failed to ensure that facility staff properly utilized accepted standard universal precautions (infection prevention practices which include, but are not limited to hand hygiene and use of gloves) while performing percutaneous endoscopic gastrostomy (PEG- a tube placed in the stomach that allows a person to receive nutrition through the tube) care for resident (R)68; failed to ensure staff did proper hand hygiene during wound care for R128; failed to ensure that staff used a protective barrier and disinfect a glucometer (a machine used to obtain blood glucose levels) while obtaining R56 blood glucose level; and failed to ensure that a container used to distribute ice to residents glasses was covered and the scoop properly stored.

Inspectors wroteThe facility identified a census of 150 residents. The sample included 26 residents; one resident sampled for discharge review. Based on observations, record reviews, and interviews, the facility failed to provide a written notification of transfer to Resident (R) 49 or to her family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to). This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare services.

Inspectors wroteThe facility identified a census of 150 residents. The sample included 26 residents, with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure reducing measures were placed on Resident (R) 128's bilateral lower extremities to prevent pressure ulcers. This placed R128 at increased risk for pressure ulcer development.

Inspectors wroteThe facility identified a census of 150 residents. The sample included 26 residents; one resident sampled for hemodialysis (procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) review. Based on observations, record reviews, and interviews, the facility failed to retain dialysis communication sheets and obtain or document vital signs and/or assessments after dialysis for Resident (R) 112. This deficient practice had the risk for adverse outcomes and unwarranted physical complications asscoaited with dialysis.

Inspectors wroteThe facility identified a census of 150 residents. The sample included 26 residents, with five residents sampled for medication review. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP- a pharmacist who works as a consultant to provide advice on the use of medications by elders) identified irregularities for two of five residents sampled for medication review: Resident (R) 20's blood pressure and/or pulse being monitored prior to administration of the beta blocker (a medication used to treat control heart rhythm, treat angina, and reduce blood pressure) carvedilol and R120's missed medication administrations with no documented physician notification of missed medications.

Inspectors wrote- R115's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R115 required limited assistance of one staff member for activities of daily living (ADL's). [...]

Inspectors wroteThe facility identified a census of 150 residents. Based on observations, record review, and interviews, the facility failed to ensure the results of the most recent health resurvey were available for residents, family, and legal representatives for review.