Saint Francis Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Saint Francis Rehabilitation and Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF658Oct 12, 2023

  Based on observation, interview, and record review it was determined that the facility failed to ensure physician orders were followed for 2 residents in a final sample of 12 residents and 1 of 27 medications observed during medication administration (Resident identifiers are #20, #3, and #13). Findings include: Standards: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 - Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . […]

• No harm, potential for more than minimal, isolatedF685Oct 12, 2023

  Based on observation, interview, and record review, it was determined that the facility failed to provide the necessary care to ensure that a resident's ability to hear was maintained with a communication device for 1 of 1 resident reviewed for communication in a final sample of 12 residents (Resident Identifier is #18). Findings include: Resident #18 Interview on 10/11/23 at 10:00 a.m. with Resident #18 revealed that his/her hearing was poor. Resident #18 was having a difficult time hearing the questions asked therefore an interview was not conducted. Observation on 10/11/23 at 10:02 a.m. revealed that Resident #18 did not have a hearing aid in either ear. Interview on 10/11/23 at 10:05 a.m. […]

• No harm, potential for more than minimal, isolatedF761Oct 12, 2023

  Based on observation, interview, and record review it was determined that the facility failed to ensure that medications were labeled and stored appropriately for 1 of 1 medication carts observed. Findings include: Birch Unit Observation on 10/11/23 at 8:36 a.m. of the Birch Unit medication cart revealed a medication cup with 7 white oval pills that were not labeled in the top drawer. Interview on 10/11/23 at 8:36 a.m. with Staff G ( Licensed Practical Nurse) confirmed the above pills were not labeled. Staff G stated medication was acidophilus and that the pill bottle was in the refrigerator. […]

• No harm, potential for more than minimal, isolatedF842Oct 12, 2023

  Based on observation, record review, and interview, the facility failed to ensure that physician orders were accurately transferred from the previous Electronic Health Record (EHR) to the current EHR for 2 out of 27 medications reviewed during medication administration (Resident Identifiers are #9 and #7). Findings include: Resident #9 Review on 10/12/23 of Resident #9's October 2023 Medication Administration Record (MAR), found in the previous EHR revealed the following physician's order for medication administration: Esomeprazole magnesium 20 mg [milligram] capsule delayed release, give 1 capsule by mouth one time a day for GERD [Gastroesophageal Reflux Disease], start date 10/3/23. […]

• No harm, potential for more than minimal, isolatedF761Nov 17, 2021

  Based on observation, interview and policy review, it was determined that the facility failed to store expired medication and label medications in accordance with currently acceptable professional standards for 1 of 1 medication carts (Birch Unit) and 1 of 2 medication storage room (Treatment Supply Room) observed. (Resident identifiers are: #13 and #30) Findings include: Birch Unit medication cart Observation on 11/16/21 at 12:15 p.m. of Birch Unit Medication cart with Staff C (Licensed Practical Nurse (LPN)) revealed an open bag of Resident #30's [MEDICATION(S)] (bronchodilator) 2.5 mg/ml (milligrams/milliliters) with expiration date of 3-2021, an unopened plastic bag of Resident #13's duo-nebs (bronchodilator) total of 90 ml's total with an expiration date of 9/2021. […]