Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
107% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
204% occupied
Based on a March 2024 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Mar 7, 2024
Visit Reason
The inspection was conducted as a complaint investigation under Complaint Number OH00150807 to assess medication administration timeliness and compliance with pharmaceutical service requirements.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00150807 and is an example of continued noncompliance from the survey dated 02/01/24.
Findings
The facility failed to ensure medications were administered in a timely manner as ordered, affecting three residents reviewed for late medications. The Director of Nursing verified late medication reports but no evidence supported timely administration.
Deficiencies (1)
F 0755: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. The facility failed to ensure medications were administered within the prescribed time frame, resulting in late medication administration for three residents.
Report Facts
Residents affected: 3
Facility census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #647 | Administered medication late to Resident #43 and verified late administration. | |
| Director of Nursing (DON) | Verified late medication reports and stated nurses were not signing out medications as administered. |
Inspection Report
Routine
Census: 52
Deficiencies: 9
Date: Feb 1, 2024
Visit Reason
Routine inspection of The Gardens of St. Francis nursing home to assess compliance with regulatory requirements including resident dignity, notification of Medicare coverage, treatment and care, accident prevention, catheter care, pain management, medication administration, and medication storage.
Findings
The facility was found deficient in multiple areas including failure to protect resident dignity, failure to provide required Medicare coverage notices, improper wound treatment application, unsafe use of transfer equipment, inadequate fall prevention interventions, improper catheter care, ineffective pain management, delayed medication administration, and unsecured medication storage.
Deficiencies (9)
F 0550: The facility failed to ensure residents were treated with dignity and respect by posting a fluid restriction sign on Resident #2's door visible to others without the resident's consent.
F 0582: The facility failed to issue required notifications of the ending of skilled Medicare Part A services to Resident #24 who remained in the facility.
F 0684: The facility failed to ensure skin breakdown treatments were applied as ordered for Resident #19, resulting in inappropriate use of wound treatment products.
F 0689: The facility failed to ensure adequate supervision and safe use of transfer equipment, resulting in actual harm to Residents #1 and #8 including falls and injuries.
F 0690: The facility failed to maintain an indwelling urinary catheter in a manner to prevent infection and dislodgement for Resident #7.
F 0697: The facility failed to ensure effective pain management for Resident #23 who was observed calling out in pain and had delayed medication administration.
F 0755: The facility failed to administer medications within ordered time frames for Resident #203, resulting in delayed medication and inhaled treatments.
F 0759: The facility failed to ensure medications were administered according to physician orders and within prescribed time frames, resulting in a medication error rate of 11.11% for Resident #154.
F 0761: The facility failed to ensure medications were stored in a safe and secure manner, leaving Resident #5's medications unsecured on a counter in the resident's room.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication error rate: 11.11
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #471 | State Tested Nurse Aide | Interviewed regarding fluid restriction sign, Resident #2's dignity, and pain management for Resident #23 |
| STNA #456 | State Tested Nurse Aide | Observed applying incorrect wound treatment for Resident #19 and catheter care for Resident #7 |
| STNA #461 | State Tested Nurse Aide | Observed unsafe use of stand-up lift with Resident #8 |
| LPN #444 | Licensed Practical Nurse | Administered pain medications to Resident #23, spilled medications, and delayed medication administration for Resident #203 |
| LPN #445 | Licensed Practical Nurse | Administered medications to Resident #154 and unaware of medication timing requirements |
| LPN #479 | Licensed Practical Nurse | Signed medication administration for Resident #5 |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including falls, catheter care, medication timing, and medication storage |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding pain management and fall interventions |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Oct 11, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to a medication error involving Resident #01 who did not receive prescribed anti-anxiety medication for three days.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00146724.
Findings
The facility failed to ensure Resident #01 received physician-ordered Klonopin for six doses over three days, resulting in a seizure attributed to medication withdrawal and hospitalization. The facility identified failures in medication ordering, follow-up with the physician and pharmacy, and documentation.
Deficiencies (1)
F 0760: The facility failed to ensure residents were free from significant medication errors when Resident #01 missed six doses of Klonopin due to lack of medication availability and follow-up. This resulted in a seizure requiring hospitalization.
Report Facts
Facility census: 54
Missed medication doses: 6
Medication tablets delivered: 60
Licensed nursing staff disciplined: 4
Audit dates: 4
Audit duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Verified medication unavailability, investigated incident, confirmed disciplinary actions and re-education of nursing staff. |
| Quality Assurance Pharmacist #200 | Quality Assurance Pharmacist | Confirmed pharmacy delivery issues and lack of facility contact with pharmacy regarding medication. |
| Administrator | Administrator | Verified medication error and implementation of plan of correction. |
| Licensed Practical Nurse #100 | Licensed Practical Nurse | One of four licensed nursing staff disciplined and re-educated related to medication error. |
| Licensed Practical Nurse #105 | Licensed Practical Nurse | One of four licensed nursing staff disciplined and re-educated related to medication error. |
| Licensed Practical Nurse #110 | Licensed Practical Nurse | One of four licensed nursing staff disciplined and re-educated related to medication error. |
| Licensed Practical Nurse #115 | Licensed Practical Nurse | One of four licensed nursing staff disciplined and re-educated related to medication error. |
| Assistant Director of Nursing #150 | Assistant Director of Nursing (ADON) | Audited residents to ensure medication availability and administration, conducted multiple audits. |
Inspection Report
Routine
Census: 53
Deficiencies: 22
Date: Sep 8, 2021
Visit Reason
Routine inspection of The Gardens of St. Francis nursing home to assess compliance with regulatory requirements including resident rights, care plans, medication administration, infection control, and facility environment.
Findings
The facility was found to have multiple deficiencies including failure to honor resident rights and choices, inadequate notification of changes in condition, failure to maintain comfortable environment, incomplete care plans, improper medication administration, inadequate infection control practices, and failure to document resident falls and hospital transfers accurately.
Deficiencies (22)
F 0550: The facility failed to treat residents with dignity, as staff did not introduce themselves to residents during care interactions.
F 0561: The facility failed to ensure residents' choices were honored, including meal preferences and requests for rest, affecting resident autonomy.
F 0580: The facility failed to notify physicians or resident representatives of changes in condition, including refusals of medical devices and falls.
F 0584: The facility failed to maintain a comfortable temperature in the main dining room, with temperatures measured below the recommended range.
F 0623: The facility failed to provide timely written notification of hospital transfers and discharges to residents, representatives, and ombudsman.
F 0625: The facility failed to notify residents or representatives in writing about bed hold policies prior to hospital transfers.
F 0641: The facility failed to accurately reflect resident hospice status in the Minimum Data Set assessment.
F 0656: The facility failed to develop and implement care plans addressing residents' respiratory status, skin conditions, fall risk, and medication monitoring.
F 0657: The facility failed to review and revise care plans after residents experienced multiple falls.
F 0677: The facility failed to provide assistance to a resident dependent on staff for eating, resulting in missed meals.
F 0684: The facility failed to provide appropriate treatment and care according to orders, including incomplete neurological checks after falls and missed skin assessments.
F 0686: The facility failed to ensure pressure relieving devices were in working condition, affecting pressure ulcer care.
F 0689: The facility failed to ensure fall interventions were in place and care plans were person-centered, with inadequate documentation of falls and missing call lights.
F 0803: The facility failed to honor resident meal preferences and offer alternates, resulting in residents receiving disliked foods without alternatives.
F 0812: The facility failed to properly cover food during hall tray delivery and failed to date food items properly in the kitchen.
F 0842: The facility failed to maintain accurate medical record documentation regarding resident falls and hospital transfers.
F 0880: The facility failed to properly wear facemasks during resident care, failed to monitor residents for COVID-19 symptoms, failed to wear N95 respirators during staff testing, and failed to store oxygen tubing properly.
F 0883: The facility failed to offer influenza vaccination to residents and lacked documentation of vaccine offers.
F 0886: The facility failed to document resident COVID-19 test results in medical records, failed to timely follow up on staff positive test results, and failed to monitor a resident who refused COVID-19 testing during an outbreak.
F 0755: The facility failed to ensure medications were administered per physician orders, including missed doses of Exelon patch.
F 0756: The facility failed to ensure resident pharmacy recommendations were addressed timely by physicians, including delayed responses to psychotropic medication recommendations.
F 0758: The facility failed to limit PRN psychotropic medications to 14 days and failed to complete renewal evaluations and supporting diagnoses for continued use.
Report Facts
Residents affected: 53
Days delayed for physician response: 49
Days PRN medication available: 37
Days PRN medication available: 21
Temperature readings missing: 5
Temperature and oxygen saturation missing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MT #347 | Maintenance Technician | Tested positive for COVID-19; delayed lab result reporting |
| LPN #373 | Licensed Practical Nurse | Performed COVID-19 testing without N95 respirator |
| STNA #319 | State Tested Nursing Assistant | Provided feeding assistance with mask below nose; delivered uncovered cupcakes |
| STNA #348 | State Tested Nursing Assistant | Provided feeding assistance with mask below nose |
| RN #323 | Registered Nurse | Verified improper oxygen tubing storage and mask use |
| DON | Director of Nursing | Verified multiple deficiencies including medication errors and documentation failures |
| LSW #333 | Licensed Social Worker | Verified lack of consent for ancillary services and vision/hearing screenings |
| HR #322 | Director of Human Resources | Verified delayed COVID-19 test result follow-up |
Inspection Report
Routine
Census: 44
Deficiencies: 5
Date: Feb 20, 2020
Visit Reason
Routine inspection of The Gardens of St. Francis nursing home to assess compliance with regulatory requirements related to resident funds security, care planning, treatment adherence, pressure ulcer care, and nutrition management.
Findings
The facility failed to maintain a surety bond sufficient to cover resident funds, did not develop a care plan for a resident's stage IV pressure ulcer, failed to follow physician orders for PICC line dressing changes, did not ensure proper pressure ulcer care including correct mattress settings and wound vacuum delivery, and failed to reassess a resident with significant weight loss.
Deficiencies (5)
F 0570: The facility failed to have a surety bond sufficient to cover resident account balances totaling $83,287.82 while the bond coverage was only $45,000.
F 0656: The facility failed to develop a plan of care addressing the treatment of a stage IV pressure ulcer for one resident.
F 0684: The facility failed to follow physician orders and policy to change PICC line dressings every seven days for one resident; no dressing changes were documented since 02/05/20.
F 0686: The facility failed to ensure a pressure relieving mattress was set correctly and did not acquire wound vacuum equipment as ordered for a resident with a stage IV pressure ulcer.
F 0692: The facility failed to reassess a resident who demonstrated significant weight loss and did not notify the physician or dietician timely.
Report Facts
Resident census: 44
Resident account balances: 83287.82
Surety bond coverage: 45000
Weight loss percentage: 6.8
Pressure ulcer wound measurements: Various measurements described in cm for Resident #39's stage IV pressure ulcer
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Verified surety bond coverage and resident account balances | |
| Business Office Manager (BOM) #150 | Verified surety bond was insufficient | |
| Director of Nursing | Verified no care plan for pressure ulcer, confirmed PICC line dressing change order not entered correctly, unaware of air mattress operation, and noted wound vacuum not delivered | |
| Licensed Practical Nurse (LPN) #311 | Verified PICC line dressing was outdated and should be changed every seven days | |
| Registered Nurse (RN) #312 | Observed dressing change and confirmed wound vacuum not delivered | |
| Registered Nurse (RN) #313 | Observed dressing change and unable to verify air mattress settings | |
| Assistant Director of Nursing #1 | Reported facility lacked mattress manufacturer directions | |
| State Tested Nursing Assistant (STNA) #200 | Reported resident weight loss and feeding assistance | |
| Licensed Practical Nurse (LPN) #310 | Verified resident weight loss and lack of notifications | |
| Dietician #420 | Reported last assessment and planned follow-up for resident weight change |
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