St. Francis Healthcare Center

Inspectors wroteCross Reference F607, F610 Based on interview and record review, the facility failed to report allegations of abuse involving one of 18 sampled residents (Resident 27) to the appropriate agencies including the California Department of Public Health (CDPH), within the required timeframe. This failure to report allegations of abuse placed Resident 27 at risk of further abuse. A review of Resident 27's Face Sheet (information containing contact details, brief medical history at-a-glance) indicated Resident 27 was admitted to the facility on [DATE] with diagnoses which hemiplegia and hemiparesis due to a stroke (hemiplegia means paralysis on one side of the body and hemiparesis means weakness in one side of the body). [...]

Inspectors wroteBased on interview and record review, the facility did not report Resident 27's alleged abuse investigation results to the State Agency. This failure placed Resident 27 at risk for further harm and abuse. A review of Resident 27's Face Sheet (information containing contact details, brief medical history at-a-glance) indicated Resident 27 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis due to a stroke (hemiplegia means paralysis on one side of the body and hemiparesis means weakness in one side of the body). [...]

Inspectors wroteBased on observation, interview, and record review, for three of 18 sampled residents (Residents 37, 3 and 6), the facility failed to ensure pharmaceutical services were provided when ordered medications were not available for administration.1. For Resident 37, the physician-ordered as-needed pain medication was not available for administration. This resulted in Resident 37's inadequate pain management.2. Resident 3's physician-ordered Namenda tablet 10 mg (Memantine HCl - indicated for the treatment of moderate to severe dementia of the Alzheimer's type) was not available for administration. This failure had the potential to result in decreased therapeutic benefit and decline in overall functioning.3. Resident 6's physician-ordered Ipratropium-Albuterol Solution (medication used to help control the symptoms of lung diseases) was not available for administration. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that medication error rate was below 5%. There were four errors out of 31 medication pass observations which resulted in 12.9% error rate. 1. Resident 6's Resident 6's physician-ordered Ipratropium-Albuterol Solution (medication used to help control the symptoms of lung diseases) was not available for administration. Resident 6's Minoxidil (medication used to treat high blood pressure) oral tablet was not administered. Resident 6's Hydralazine (medication used to treat high blood pressure) oral tablet was not administered. These failures had the potential to affect Resident 6's health and safety due to worsening of respiratory illness and high blood pressure.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage of medications when:- East Medication Cart had multiple medications that were either opened without open date or were stored beyond use-by dates.- A bottle of Potassium Chloride solution (used to treat low levels of potassium, a mineral, in a patient's blood) was stored outside the required temperature. - Narcotic storage safe was not permanently affixed. These deficient practices had the potential to result in unauthorized access, compromised medication integrity, and increased risk of medication errors for all residents who rely on the facility for safe medication management. During a concurrent observation and interview on 4/7/26 at 3:02 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that potentially hazardous foods (Foods that must be kept at a particular temperature to minimize the growth of food poisoning bacteria that may be in the food, or to stop the formation of toxins are cooled rapidly) were kept in proper temperature before storing. Cool Down Log's consistently listed the expected temperature of the menu items monitored at 1 hour, 2 hours, and at 4 hours. These failures had the potential to cause food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection control program when: The following infection control issues were identified regarding Resident 5: a. Intravenous fluid bag that was not infused remained hung and connected to the resident's midline catheter (Intravenous fluid therapy, commonly referred to as IV fluid therapy, is a medical term that delivers fluids directly into the bloodstream to correct a medical condition. A midline catheter is an IV catheter that is inserted in the vein in the upper arm used to deliver the IV fluids to the resident's body).b. Resident 5's midline dressing was peeling off, compromising the site.c. [...]

Inspectors wroteBased on observation, interview and record review, for one of one sampled resident (Resident 23) reviewed for limited range of motion and one randomly sampled resident (Resident 34), the facility failed to ensure residents were treated with dignity and respect during meal service when:1. For Resident 23, who was diagnosed with Parkinson's disease (a progressive, incurable neurological disorder leading to movement issues like tremors, stiffness, and slow movement), staff failed to assist Resident 23 with meals. This failure resulted in difficulty managing use of utensils and consuming the meal.2. Certified Nursing Assistant (CNA) assisted Resident 34 with eating while standing over the resident, rather than sitting or positioning themselves at eye level. This failure had the potential to result in a lack of dignity, comfort, and appropriate interaction during mealtime. [...]

Inspectors wroteBased on observation, interview, and record review, for one of two residents reviewed under personal property (Resident 44), the facility failed to exercise reasonable care for the protection of the residents' personal property from potential theft or loss when staff did not complete a timely and accurate reconciliation of Resident 44's personal items inventories. This failure had the potential to result in outdated and incomplete inventory records and potentially result in property loss. During a review of Resident 44's admission Record (AR), the AR indicated Resident 44 was admitted to the facility on [DATE] and was discharged on 3/20/26. During a telephone interview on 4/7/26 at 12:07 p.m. with Resident Representative (RR) 1, RR 1 stated when RR 1 came to the facility to retrieve Resident 44's personal belongings, RR 1 noted several items were missing. [...]

Inspectors wroteCross Reference F609, F610 Based on interview and record review, the facility failed to follow its written policies prohibiting resident abuse, impacting one of 18 sampled residents (Resident 27). This failure to report allegations of abuse placed Resident 27 at risk of potential abuse. Review of Resident 27's Face Sheet (information containing contact details, brief medical history at-a-glance) indicated Resident 27 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis due to a stroke (hemiplegia means paralysis on one side of the body and hemiparesis means weakness in one side of the body). [...]

Inspectors wroteBased on interview and record review, the facility did not verify Resident 5's Intravenous (IV) fluids order with the physician ( IV fluids are sterile liquids like water, salt, or sugar solutions that are delivered directly into a vein through a tube . They bypass the digestive system for fast absorption in the body). This failure had the potential to result in life-threatening complications for Resident 5. A review of the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses which included dysphagia ( difficulty swallowing), dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) and congestive heart failure (the heart muscle is too weak or stiff to pump blood efficiently, causing blood to back up and fluid to build up in the body). [...]

Inspectors wroteBased on interview and record review, for one of one resident (Resident 44) reviewed for significant medication errors, the facility failed to ensure medications were administered as prescribed by the physician when Registered Nurse (RN) 4 administered 11 units of insulin (a hormone produced by the pancreas that regulates blood sugar by moving glucose into cells for energy) instead of the physician-ordered 6 units. This failure resulted in Resident 44 receiving nearly double the prescribed dose, placing the resident at increased risk of hypoglycemia (abnormally low blood glucose/sugar) and other adverse clinical outcomes. [...]

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 66) reviewed for closed record, the facility failed to maintain complete and accurate medical records in accordance with professional standards when: Resident 66 left the faciity on 2/12/26 without staff knowledge or permission (elopement, when a resident leaves the facility without staff knowledge or permission), and this was documented in the medical record as leaving Against Medical Advice (AMA, a situation in which a resident chooses to leave a healthcare facility or discontinue recommended care despite the facility's clinical advice to remain). This failure had the potential to result in miscommunication and lack of coordination of care. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: [NAME] (CK) 1 did not wear a beard restraint while preparing resident food. The kitchen dry storage, refrigerator, and resident refrigerator had multiple beyond use by date food items. Food items in the dry storage were stored less than six inches from the floor. The ice scoop was open to air. These failures had the potential for contamination of food resulting in food borne illness for the 54 residents who received food from the kitchen. During a concurrent interview and observation on 7/21/25, at 10:00 a.m. with CK 1, CK 1 stated they were preparing French bread for the resident's lunch. CK 1 was not wearing a beard restraint, and their mustache and sideburns were uncovered. [...]

Inspectors wroteBased on interview and record review skilled nursing license staff did not accurately assess the healthcare status of one of 15 sampled residents (Resident7). Resident 7 was screaming and staff administered anti-anxiety medication without assessing its effectiveness. This resulted in an inability to fully assess Resident 7's mental health status. Record review of the document admission Record showed the facility admitted Resident 7 on 6/10/2025. Diagnoses included difficulty speaking and swallowing following a stroke. Record review of the document MDS 3.0 Nursing Home Comprehensive (NC) Version 1.19.1 (Resident Assessment) showed Resident 7 was Rarely/Never Understood. Record review of the document Care Plan Report dated 11/14/2024, showed Resident 7 was diagnosed with Generalized Anxiety Disorder and was being administered antianxiety medication. [...]

Inspectors wroteBased on observation, interview, and record review, licensed nursing staff did not fully assess and treat the declining mental status for one of 15 sampled residents (Resident 36). Resident 36 had been declining the use of medication to treat a mental condition. The medication also became unavailable through the pharmacy. Staff did not follow up with the physician to initiate a new plan of treatment. This resulted in the high probability Resident 36 experienced unnecessary behaviors and falls. Record review of the document admission Record showed the facility admitted Resident 36 on 1/14/2021 and diagnoses included Paranoid Schizophrenia (a mental illness characterized by disturbances in thinking, perception, and behavior. [...]

Inspectors wroteF761 Labeling and Storage of Drugs and Biologicals Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices in the medication storage room (a locked room used to store medications and medical supplies) when following was noted: A. In the medication and medical supplies cart (a mobile cart that stored medication and supplies for immediate use), there were: 1. Two vials of four milligrams/four milliliters (4mg/4 ml) Lasix (furosemide, diuretic medication to eliminate excess fluid from the body) for Resident 67 were kept inside a brown plastic bag. The bag had sticky liquid sticking to it and it was kept in the first drawer of the cart.2. An opened, used, multi-dose vial of Tuberculin Purified Protein Derivative (Mantoux) (a substance used in a skin test to help diagnose tuberculosis (TB) infection) was not dated.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision of two of three sampled residents (Resident 1 and Resident 2). The facility failed to ensure the two residents who were roomed together and had the same surname were properly identified by facility staff before initiating a transfer for dialysis treatment. The facility failed to ensure staff properly identified Resident 1 so Resident 1 could be sent for dialysis treatment (a treatment for kidney failure to remove waste products and excess fluids by external filtration of blood). These failures resulted in Resident 2 being unnecessarily transported to the dialysis center, and a one-hour delay in pick-up for Resident 1's dialysis treatment. For Resident 1, the one-hour delay in pick-up for dialysis had the potential to result in shortened or unavailable dialysis treatment. [...]

Inspectors wroteBased on observation, interview, and record review, for one of five sampled residents (Resident 38) who were reviewed for unnecessary medications use, the facility failed to ensure: 1. Resident 38 was given antipsychotic medication (medication to help reduce psychotic symptoms like hallucinations, delusions, and disordered thinking) to treat a specific condition. 2. Resident 38 was given antipsychotic medication with adequate monitoring of adverse effects from the medication. These failures had the potential to result in unnecessary use of antipsychotic medication and delayed management of adverse effects.

Inspectors wroteBased on interview and record review, the facility failed to operate and provide services in compliance with State regulations when an unusual occurrence of a fall with major injury was not reported to the State Agency. This failure had the potential to result in the lack of oversight for resident safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure to discharge on e of three sample selected residents (Resident 1) safely to an appropriate place, when the facility discharged Resident 1 to an independent living facility while Resident 1 needed a higher level of care. This deficient practice resulted in Resident 1 eloping (leaving a facility when doing so may present an imminent threat to the patient's health or safety) from the independent living facility and found by police wandering the streets resulting in hospitalization.