St. Francis Health Services

Inspectors wroteBased on observation, interview and record review, the Facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R43 & R4) of 3 Residents reviewed for pressure injuries. *R43 is dependent for all cares, requires substantial/maximal assistance with bed mobility and is at risk for developing pressure injuries. On 12/24/2025, the Facility implemented a care plan for R43's risk for pressure injuries with interventions not supportive of R43's needs. On 1/27/2026, R43 developed a Deep Tissue Injury (DTI) (an injury which occurs with prolonged pressure and shear forces) to R43's bilateral heels. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that it did not employ individuals who were found guilty of abuse, neglect, exploitation or mistreatment by failing to conduct a background information disclosure every four years for 1 (Social Services (SS)-G) of 8 facility staff reviewed. This deficient practice has the potential to affect residents who may receive care from SS-G.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure medications were stored in accordance with facility policy and procedures for 1 of 1medication room reviewed for medication storage.*On 2/17/2026, at 7:29 AM, Surveyor observed the door to the medication room wide open, and the door propped open with a doorstop. Surveyor noted an open plastic bin with medication packages inside and easily accessible.*On 02/17/2026, at 1:52 PM, Surveyor observed the vaccine refrigerator to read 30 degrees Fahrenheit with frost build up on the inside of refrigerator.

Inspectors wroteBased on interview and record review, the facility did not complete a significant change in status Minimum Data Set (MDS) assessment for 1 (R30) of 1 resident reviewed for hospice. R30 enrolled in hospice services on 12/26/25. The facility did not complete a Significant Change MDS until 1/26/26.

Inspectors wroteBased on interview and record review, the facility did not transmit a discharge assessment within 7 days after completion for 1 (R19) of 1 residents reviewed for late Minimum Data Set (MDS) assessments.*R19 discharged to the hospital on 8/30/2025. The Discharge Return Anticipated (DCRA) MDS assessment dated [DATE] was completed but not submitted.

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure residents with hearing impairment received proper treatment and assistive devices to maintain hearing abilities for 1 of 1 (R2) residents reviewed for hearing.* Surveyor observed R2 to be very hard of hearing and not wearing hearing aids. According to R2's most recent audiology consult, and R2's annual Minimum Data Set (MDS), R2 uses hearing aids. The facility failed to ensure R2 received treatment and assistive devices to maintain hearing abilities.

Inspectors wroteBased on record review and staff interviews, the facility did not always ensure that 1 out of 1 residents ( R6) reviewed for urinary incontinence received the necessary care and services to maintain or restore bladder incontinence. R6 experienced a decline from frequently incontinent of urine to always being incontinent of urine and the facility did not implement interventions in place to help restore R6's urinary continence. This is evidenced by: R6 was admitted to the facility on [DATE] with diagnosis that included Nontraumatic intracerebral hemorrhage, epilepsy, dementia, mood disorder, hypertension, hyperlipidemia and unspecified psychosis. R6's most recent annual MDS ( Minimum Data Set) dated 4/19/25 documents that R6 is frequently incontinent of urine and a trial of a toileting program, prompted voiding or bladder training has not been attempted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R3) of 12 residents observed. During observation of catheter care for R3, certified nursing assistant (CNA)-I did not perform appropriate hand hygiene or wear a gown when enhanced barrier precautions (EBP) were in place for R3.

Inspectors wroteBased on record review, interview, review of the Misconduct Incident Report, and facility policy review, the facility failed to ensure that a thorough investigation was documented regarding a potential visitor-to-resident altercation for one (R1) resident out of a sample of 14 residents reveiwed for abuse.

Inspectors wroteBased on staff interview, and record review, the facility did not maintain an effective infection control program under which it investigates, controls, and prevents infections in the facility. * Total infection rates were not calculated accurately and rates of infection for individual infection types were not calculated. Since infection rates were not calculated it was not possible to analyze the data to determine if there was a rise in the prevalence of infections from month to month with a potential to affect 29 of 29 residents.

Inspectors wroteBased on interview and record review, the facility did not ensure 4 (R3, R9, R5 and R14) of 4 residents reviewed for hospitalizations received a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. *R3 was transferred to the hospital while residing in the Facility and evidence was not provided that they or their representative were given the required transfer notice information. *R9 was transferred to the hospital while residing in the Facility and evidence was not provided that they or their representative were given the required transfer notice information. *R5 was transferred to the hospital while residing in the Facility and evidence was not provided that they or their representative were given the required transfer notice information. [...]

Inspectors wroteBased on observations, interview, and record review, the facility did not ensure residents received adequate supervision to prevent accidents for 1 (R22) of 1 residents reviewed for falls. *R22 had three unwitnessed falls that were not thoroughly investigated to determine a root cause and develop interventions that addressed the cause and prevent future falls.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure food was prepared and served in a form designed to meet individual needs for 1 (R15) of 1 residents reviewed for a mechanically-altered diet. R15 has a puree diet order (level 1), R15 was served a meal tray with a banana cut in half, not pureed as per R15's diet order and meal ticket specification.

Inspectors wroteBased on observation, interview, and record review, the Facility did not ensure food was prepared and served in a sanitary manner. This practice affected 1 of 2 residents with a mechanically-altered diet. R15 was served pureed food that was not brought up to the correct temperature to prevent bacteria growth in the danger zone (below 135 degrees F) The [NAME] was observed changing gloves with no handwashing after gloves were removed, before a new pair of gloves were put on.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure food was stored, prepared and served under sanitary conditions in 1 of 1 kitchens. This had the potential to affect all 32 Residents. *On 1/30/24 and 1/31/24, during the main kitchen tour, Surveyor observed multiple pieces of kitchen equipment that were not clean. *On 1/31/24, at 7:40 AM, Surveyor observed the robot coupe food processor with splattered food dried on the outside, and crumbs in the crevices. *On 1/30/24 and 1/31/24, Surveyor observed Resident room trays being distributed without lids on the main entree, all cups of liquid, and side dishes were not covered. *The internal dishwashing machine temperature was not being monitored and staff in the dish machine area did not know how to monitor the dishwashing temperatures to ensure dishes & utensils were being sanitized correctly. Findings Include: [...]