The Gardens of St. Francis

In the surveyor’s words

From the most serious findings on record at The Gardens of St. Francis, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 1, 2024

  Based 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. […]

• Actual harm, isolatedF760Oct 11, 2023

  THE 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, isolatedF881May 4, 2021

  Based on review of physician orders, review of the nurses notes, review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . This caused harm when one resident (#36) who was administered antibiotics for more than 120 days in the past eight months for asymptomatic urinary tract infections from developing [CONDITION(S)] (antibiotic associated diarrhea infection). This affected one (#36) of three residents reviewed for urinary tract infections. The facility census was 53. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/07/21 revealed the resident had impaired cognition. […]

• No harm, potential for more than minimal, widespreadF812Sep 8, 2021

  Based 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. Findings include: 1. Observation on 08/30/21 at 11:44 A.M. of hall tray service on the C Hall revealed the meal cart was placed in the common area of the hall. State tested Nursing Assistant (STNA) #319 was observed removing lunch trays from the meal cart, walking down the hall and delivering to the resident rooms. […]

• No harm, potential for more than minimal, widespreadF880Sep 8, 2021

  Based 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. Findings include: 1. Observation on 08/30/21 at 8:05 A.M. […]