Inspection Reports for Franklin Heights Nursing and Rehab Center

The facility failed to ensure that residents were free from physical restraints, specifically pillows tucked under mattresses that restricted movement for two residents. This practice was not medically necessary and posed risks of injury and restricted freedom of movement.

The complaint investigation revealed that Resident #1 was administered oral medications by CMA B despite having a PEG tube and physician orders specifying medication administration via the PEG tube. The resident received unprescribed medications including Amiodarone, which could cause serious adverse effects. CMA B was suspended and later terminated. The facility monitored the resident for complications and notified the physician and family.

The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1 and failed to follow the care plan and physician's orders during medication administration. Resident #1 was given oral medications despite having a PEG tube for medication administration, resulting in a medication error where unprescribed medications, including Amiodarone, were administered. The facility failed to prevent significant medication errors, placing the resident at risk of harm.

The complaint investigation was substantiated with findings that the facility failed to provide required written notices for room transfers, failed to provide notices in understandable formats and languages, failed to assist residents with ADLs including nail care, failed to maintain medication cart cleanliness, failed to store and prepare food safely, failed to maintain accurate medical records, and failed to maintain an effective pest control program.

The facility failed to provide written notice of room transfers to residents and their responsible parties, failed to ensure residents received notices in a language they understood, failed to provide adequate assistance with personal hygiene including nail care for some residents, failed to maintain cleanliness of medication carts, failed to store and prepare food in accordance with professional standards including sealing containers and disposing of spoiled food, failed to maintain complete and accurate medical records documenting room transfers and reasons, and failed to maintain an effective pest control program resulting in presence of cockroaches in the kitchen.

The complaint investigation was substantiated with findings that the facility failed to provide required written notices for room transfers to residents and their responsible parties, failed to provide residents with adequate information about advocacy resources, failed to provide proper ADL care, failed to maintain food safety and pest control standards, and failed to maintain accurate medical records.

The facility failed to provide written notice of room transfers to several residents and their responsible parties, failed to ensure residents had information about advocacy resources, failed to provide adequate ADL care including nail care for some residents, failed to maintain food safety standards in the kitchen, failed to maintain complete and accurate medical records regarding room transfers, and failed to maintain an effective pest control program resulting in cockroach presence in the kitchen.

The visit was complaint-related focusing on resident rights violations, call light accessibility issues, catheter care deficiencies, and respiratory care concerns. The complaints were substantiated with observations, interviews, and record reviews.

The facility failed to ensure resident privacy regarding catheter collection bags, failed to keep call lights within reach for residents, did not secure catheter tubing properly, and did not maintain oxygen humidifier bottles filled during oxygen therapy. These failures posed risks to resident dignity, safety, and health.

The facility was found deficient in multiple areas including failure to treat residents with dignity during feeding, failure to report and investigate allegations of medication theft, inaccurate resident assessments, incomplete care plans, inadequate personal hygiene assistance, medication administration errors, poor infection control practices, unsafe food storage and preparation, incomplete nurse staffing postings, and failure to maintain essential equipment.

The facility failed to administer medication as ordered to a resident, maintain proper drug destruction records, keep medication carts clean, date glucose control solutions, maintain infection control standards including proper handling of catheter bags and linen carts, maintain kitchen equipment and safe dishwashing procedures, and control pests effectively with live cockroaches found in resident areas.

The facility failed to reasonably accommodate the needs of Resident #6 by not ensuring the call light was within reach, and failed to notify hospice of Resident #1's acute glucose level increase, potentially risking substandard care due to miscommunication.

The complaint involved allegations of missing money ($400) from Resident #2's wallet and neglect related to wound care for Resident #6. The facility did not report the alleged misappropriation to the state agency, citing inconsistent resident statements and no confirmed misappropriation. The neglect allegation for Resident #6 was investigated and found unsubstantiated. The complaint also included failure to provide wound care for Resident #3.

The facility failed to timely report alleged violations involving neglect and misappropriation for Resident #2 and Resident #6, and failed to provide wound care as prescribed for Resident #3. Investigations found inconsistent resident statements and no substantiated misappropriation or neglect for Resident #2 and #6. Resident #3 did not receive wound care as ordered, posing risk of wound deterioration.

The complaint investigation involved allegations of sexual abuse by CNA H against Resident #2, failure to report and investigate the abuse timely, failure to prevent elopement of Resident #1, and failure to provide appropriate catheter care and supervision. The facility was found to have Immediate Jeopardy related to sexual abuse reporting and elopement prevention. The IJ was removed after corrective actions including staff suspension, in-services, monitoring, and revised policies.

The facility failed to ensure resident dignity with catheter care, failed to keep call lights within reach, failed to prevent and properly investigate sexual abuse allegations, failed to prevent elopement and ensure supervision in the patio area, and failed to properly document medical records and assessments related to abuse allegations. Immediate Jeopardy was identified related to sexual abuse reporting and elopement prevention but was removed after corrective actions.

The complaint investigation focused on multiple issues including resident rights violations, privacy breaches, environmental safety hazards, failure to report and investigate injuries of unknown origin, inaccurate assessments, inadequate care planning, elopement incidents, and respiratory care deficiencies. Immediate jeopardy was identified related to elopement and supervision failures.

The facility failed to promote resident self-determination, respect privacy during care, maintain a safe environment, report and investigate injuries of unknown origin, ensure accurate assessments and care plans, provide adequate supervision to prevent elopement, and provide proper respiratory care. Immediate jeopardy was identified related to elopement and supervision failures.

The facility failed to develop and implement comprehensive person-centered care plans for residents requiring oxygen therapy and those refusing certain care interventions. Additionally, the facility did not ensure safe respiratory care practices, including posting oxygen signs and proper handling of nasal cannulas. Infection control deficiencies were noted with uncovered linen carts and improper handling of contaminated equipment, placing residents at risk of infection.

The investigation was complaint-related, focusing on Resident #1's care plan deficiencies and hospice service communication failures. The complaint included concerns about Resident #1's skin condition, refusal of care, and lack of proper bathing and brief changes. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to develop a care plan addressing Resident #1's refusal of help with activities of daily living, resulting in increased risk of impaired skin integrity and decreased quality of life. Additionally, the facility failed to ensure accurate communication and documentation of hospice services provided to Resident #1, leading to undetected gaps in bathing services.

The facility failed to provide personal clothing to residents, develop accurate care plans, ensure timely repositioning, maintain proper nutrition monitoring, administer medications according to orders, and uphold food safety standards including proper food labeling, temperature monitoring, and hygiene practices.

The facility was found deficient in ensuring residents had call bells within reach, securing medication carts when unattended, and maintaining proper infection control practices, specifically hand hygiene after perineal care.