The resident, identified as R25 in inspection documents, has been at Wheaton Franciscan Healthcare - Terrace at St Francis since February but was only approached about dental care after inspectors brought the issue to facility administrators' attention in July.
"I have to. I want to be seen by a dentist," the resident told inspectors when asked directly if she wanted dental services.
The facility's own policy requires routine dental services to meet residents' oral health needs. Staff are supposed to notify social services when residents need dental care, and social services personnel should assist with making appointments.
But when inspectors interviewed Social Worker SW-O on July 17, she indicated the resident "may have refused services" and would look for documentation. Medical Records staff member MR-R had no record of the resident being on the dental list.
The resident's dietitian had documented in February that she had "chewing difficulty" and was on a mechanically soft diet with tube feedings because nursing reported she was only consuming pudding.
The facility's nursing home administrator told inspectors they offer dental services within six months of admission, but no documentation was provided showing the resident had been offered these services. The first discussion with the resident about dental care occurred only after inspectors raised the concern.
The dental care failure was one of multiple violations found during the July inspection that affected basic resident care and safety.
Another resident with Parkinson's disease and very shaky hands was denied the special eating utensils recommended by the facility's own dietitian. The resident, R40, told inspectors on July 15 that she had asked for help eating but was told no one was available.
"It's hard to eat when she is this shaky," the resident explained to inspectors, who observed her unable to pick up a foam cup or use metal utensils.
The dietitian had documented on June 18 that R40 needed "special utensils and cups." A nursing note from June 17 described how staff worked with the resident on drinking techniques, noting she "needs help holding her cup."
But when inspectors observed meals being served, R40 received standard metal utensils and styrofoam cups. The Director of Nursing told inspectors she "did not see the dietary assessment note about special utensils for R40 until surveyor pointed it out."
Special assistive eating equipment was only provided to R40 on July 18, after inspectors had identified the problem.
The facility also failed to maintain basic infection control standards that put all 47 residents at risk.
Staff repeatedly violated enhanced barrier precautions for a resident with a stage 3 pressure injury. On July 16, inspectors observed two nursing assistants repositioning the resident without wearing required gowns, despite facility policy requiring gown and gloves for any contact with residents on enhanced barrier precautions.
During another observation on July 18, a nursing assistant performed extensive personal care including cleaning bowel movements and applying incontinence products without changing gloves or performing hand hygiene between dirty and clean tasks.
A registered nurse treating the resident's pressure wound also failed to perform hand hygiene after cleaning the injury, before applying the new dressing.
The facility's infection control problems extended beyond individual care incidents. Staff routinely left one resident's urinary catheter bag on the floor, violating the facility's own policy requiring catheter bags be kept off the floor.
Inspectors observed the catheter bag on the floor multiple times over three days. On July 15, a nursing assistant woke the resident for lunch while standing directly next to the catheter bag on the floor but did not pick it up. The bag remained on the floor for hours at a time.
When questioned, the unit manager acknowledged catheter bags should not be on the floor but suggested the resident sometimes removes the bag from the bed herself.
Food service operations also violated safety standards. A food service worker with a visible beard prepared resident meals without wearing a required beard net on multiple occasions. The facility's policy explicitly requires all facial hair be restrained with beard nets when working with food.
The facility's dish washing equipment consistently failed to reach minimum required temperatures. On two floors, dish machines operated at temperatures as low as 110 degrees, well below the 120-degree minimum required by facility policy and far below the 140 degrees specified by the manufacturer.
Food service staff admitted they routinely failed to test sanitizer chemical levels, despite facility policy requiring testing with each meal. When inspectors asked about test strips, one worker had to dig through drawers to find them. Three different food service workers confirmed they did not use the test strips regularly.
Review of dish machine logs revealed that out of 90 possible meal periods in May and June, only 41 meals on the second floor and just three meals on the third floor reached minimum temperature requirements. The same sanitizer reading of 100 parts per million was recorded for nearly every meal, suggesting staff were not actually testing but simply writing the same number repeatedly.
The facility's water management program, designed to prevent Legionella bacteria growth, had not been updated to reflect current staff or building changes. One wing of the facility had been closed since March, but the water management plan had not been revised to address the increased risk from stagnant water in unused areas.
No water temperature monitoring logs had been completed for over a year, despite monthly requirements. The facility had no defined program for flushing little-used water outlets, and required chlorine testing was not being performed.
Hospice care coordination also broke down for two residents. For one resident receiving hospice services since September 2023, no hospice visit notes could be located in either the medical record or hospice binder. Staff were unsure who the current hospice case manager was or when visits occurred.
"I don't know the exact day but when they do come I encourage her to do her cares," one nursing assistant told inspectors when asked about the hospice schedule.
The facility had no designated liaison to coordinate with hospice providers, despite a contract requiring such coordination. The Director of Nursing admitted she didn't know the process for hospice communication and "doesn't like the process" and planned to change it.
For a second hospice resident, the most recent recertification of terminal illness in the facility's records was over a year old. There was no current list of hospice staff with contact information, and facility nurses reported communication problems with the hospice team.
The hospice nurse told inspectors there had been "multiple times" when she communicated care issues or changes to facility nursing staff that were "not addressed by facility nursing staff timely or not at all."
A medication management violation involved a hospice resident whose anxiety medication lacked proper documentation. The resident had been receiving Ativan as needed since May, but there was no documented rationale for continuing the medication beyond the standard 14-day limit and no stop date until inspectors raised the issue.
The nursing home administrator provided updated physician orders with a stop date only after inspectors had spent three days questioning staff about the missing documentation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wheaton Franciscan Hc - Terrace At St Francis from 2024-07-22 including all violations, facility responses, and corrective action plans.
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