St. Francis Home

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 74 of 74 residents residing in the facility. The facility did not ensure time/temperature control foods were labeled appropriately with open and/or use-by dates.

Inspectors wroteBased on staff interview and record review, the facility did not ensure their abuse policy was implemented for 2 of 8 employees reviewed for employee reference checks. This practice had the potential to affect more than 4 of the 74 residents residing in the facility. The facility did not complete reference checks for Certified Nursing Assistant (CNA)-F and CNA-G.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the necessary care and services to monitor weight gain was provided 1 resident (R) (R5) of 2 sampled residents. R5's weight was not monitored as ordered. In addition, R5's physician was not notified as ordered when R5 gained 3 pounds or more in one day.

Inspectors wroteBased on staff interview and record review, the facility did not ensure fistula monitoring and pre-treatment dialysis forms were completed for 1 resident (R) (R5) of 1 sampled resident. R5's Treatment Administration Record (TAR) indicated R5's fistula wasn't consistently monitored. In addition, R5's pre-treatment dialysis forms were not consistently completed.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 3 residents (R) (R1, R6, and R39) of 3 sampled residents. R1 was on enhanced barrier precautions (EBP) for an indwelling catheter and wounds. During care observations and medication administration, staff did not adhere to EBP. R6 was on EBP for an indwelling catheter. During care and therapy observations, staff did not adhere to EBP. R39 had an order for EBP due to an indwelling catheter; however, there was not an EBP sign outside R39's room. During a care observation, staff did not adhere to EBP. In addition, R39's care plan did not indicate R39 was on EBP.

Inspectors wroteBased on staff interview and record review, the facility did not report an allegation of misappropriation of contingency medication to the State Agency (SA). This had the potential to affect residents in the facility who may have needed contingency medications that were potentially diverted. On 1/11/25, the facility discovered missing doses of narcotic medication which raised the concern of potential drug diversion. The facility did not report the allegation of misappropriation to the SA.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 8 residents (R) (R57, R28, R54, R186, R73, R30, R44, and R38) of 8 sampled residents. This practice had the potential to affect all 74 residents residing in the facility. The facility's line list for a current gastrointestinal outbreak (GI) of Norovirus was inaccurate for R57, R28, R54, R186, and R73. R30 was on enhanced barrier precautions (EBP) and had an EBP sign posted on R30's door. On 12/16/24, Certified Nursing Assistant (CNA)-P repositioned R30 without wearing the appropriate personal protective equipment (PPE). R44 was on EBP related to wounds and had an EBP sign posted on R44's door. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure call lights were in reach for 5 residents (R) (R44, R10, R60, R38, and R285) of 21 sampled residents. R44, R10, R60, R38, and R285 were dependent on staff for mobility and cares. During observations on 12/16/24 and 12/17/24, R44, R10, R60, R38, and R285's call lights were not within reach.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a written transfer notice was provided for 1 resident (R) (R11) of 6 residents reviewed for hospitalization. In addition, the facility did not ensure the Ombudsman was notified of hospital transfers for 6 (R11, R33, R21, R30, R59, and R82) of 6 residents. R11 was transferred to the hospital on 2/22/24 and 5/1/24. Neither R11 or R11's Power of Attorney (POA) were provided with a written transfer notice for R11's 5/1/24 hospital transfer. In addition, the facility did not notify the Ombudsman of R11's hospital transfers. R33 was transferred to the hospital on 8/7/24. The facility did not notify the Ombudsman of R33's hospital transfer. R21 was transferred to the hospital on [DATE]. The facility did not notify the Ombudsman of R21's hospital transfer. R30 was transferred to the hospital on 6/30/24. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure a physician was notified when 1 resident (R) (R186) of 1 sampled resident had a blood sugar outside the parameters of a physician's order. R186 had an order to notify the physician if R186's blood sugar was higher than 400 mg/dL (milligrams per deciliter) or less than 60 mg/dL. On 12/15/24, R186's blood sugar was 409 mg/dL. R186's physician was not notified.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 2 residents (R) (R11 and R33) of 6 residents reviewed for hospitalization received written notification of the facility's bedhold policy when they were transferred to the hospital. R11 was transferred to the hospital on 2/22/24. The facility did not obtain written bedhold confirmation from R11 or R11's Power of Attorney (POA). In addition, R11 was transferred to the hospital on 5/1/24. Neither R11 or R11's POA were provided with a written bedhold notification for R11's 5/1/24 hospital transfer. R33 was transferred to the hospital on 8/7/24. The facility did not obtain written bedhold confirmation from R33 or R33's emergency contact.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were coded correctly for 2 residents (R) (R11 and R19) of 21 sampled residents. R11 was prescribed lorazepam (an anti-anxiety medication) and oxycodone (an opioid medication). R11's MDS assessments, dated 5/21/24, 6/24/24 and 9/20/24, did not indicate R11 received anti-anxiety or opioid medication. R19 had a diagnosis of mental illness (MI). R19's MDS assessment, dated 8/6/24, indicated R19 did not have a serious mental illness.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the appropriate care and treatment were provided for 1 resident (R) (R54) of 1 resident reviewed for weight monitoring. The facility did not ensure R54's physician was notified when R54 had a significant weight gain. In addition, the facility did not consistently monitor R54's weight per the physician's order.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure the safe administration of drugs and biologicals for 2 residents (R) (R27 and R78) of 21 sampled residents. On 12/16/24, Surveyor observed two inhalers on R27's bedside table. R27 indicated R27 self-administered the inhalers as needed. A self-administration of medication assessment, dated 9/24/24, determined R27 was unable to self-administer medication. On 12/17/24, R78's 500 milligram (mg) ranolazine (used to treat chest pain) tablet was administered late.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring for high risk medications was in place for 3 residents (R) (R30, R69, and R11) reviewed for unnecessary medications. R30 was prescribed hydrocodone-acetaminophen (an opioid medication) for pain. R30 was not monitored for adverse reactions or side effects of the high-risk medication. R69 was prescribed oxycodone (an opioid medication) for pain. R69 was not monitored for adverse reactions or side effects of the high-risk medication. R11 was prescribed oxycodone and torsemide (a diuretic medication) for congestive heart failure (CHF). R11 was not monitored for adverse reactions or side effects of the high-risk medications.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 3 errors occurred during 32 opportunities which resulted in a 9.37% medication error rate that affected 1 resident (R) (R21) of 3 residents observed during medication administration. On 12/17/24, R21 was administered two medications in the wrong form and one incorrect medication.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure an injury of unknown source involving potential abuse/neglect was reported to the State Agency (SA) in a timely manner for 1 Resident (R) (R1) of 4 sampled residents. On 6/30/24, R1 had a fall with major injury. The facility did not submit a 5-day investigation to the SA in a timely manner. In addition, the report submitted to the SA had incorrect information.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an environment free of accident hazards for 2 Residents (R) (R1 and R3) of 4 sampled residents. On 4/8/24 and 6/21/24, R1 experienced falls. The facility did not revise R1's care plan to help prevent future falls. On 4/5/24, R3 slapped R2 on the arm and told R2 to shut up. The facility did not revise R3's care plan to include measures to prevent R3 from further inappropriate interactions toward residents.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure interventions were implemented to reduce accidents and hazards and ensure a safe environment for 4 Residents (R) (R1, R8, R2, and R3) of 6 residents reviewed for fall prevention and supervision. R1's care plan contained an intervention that instructed staff not to leave R1 alone in the bathroom. The intervention was not consistently implemented. R8's care plan contained an intervention to transfer R8 with a sit-to-stand lift and the assistance of 2 staff. The intervention was not consistently implemented. A facility-reported incident (FRI), dated 12/19/23, indicated an intervention was added to R2's care plan for a stop sign banner across R2's doorway at night. The intervention was not consistently implemented or added to R2's care plan prior to 1/11/24. [...]

Inspectors wroteBased on resident and staff interview, and record review, the facility did not ensure timely reporting of an injury of unknown origin for 1 Resident (R) (R2) of 4 residents reviewed. R2 was diagnosed with a hip fracture of unknown origin. The injury was not reported to the State Agency (SA) within two hours of discovery.

Inspectors wroteBased on resident and staff interview, and record review, the facility did not ensure an injury of unknown origin was thoroughly investigated for 1 Resident (R) (R2) of 4 residents reviewed. R2 incurred a hip fracture of unknown origin. The injury was not thoroughly investigated.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Transmission-Based Precautions (TBP) were implemented for 3 Residents (R) (R33, R70 and R71) of 3 residents. In addition, the facility did not have a system to identify, monitor and prevent the spread of infections and communicable diseases. The facility did not initiate TBP when R33 was symptomatic and tested positive for Clostridioides Difficile (C.diff) (a contagious infection caused by the bacteria Clostridioides difficile which can be spread person-to-person or on surfaces; symptoms include watery diarrhea, fever, nausea, and abdominal pain). The facility did not initiate TBP when R70 was symptomatic and required treatment for pneumonia (an inflammatory condition of the lungs caused by bacteria or a virus that primarily affects the small air sacs known as alveoli; [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 Residents (R) (R17 and R61) of 5 residents reviewed for unnecessary medications and their legal representatives were informed in advance of the risk and benefits of prescribed psychotropic medications. R17 was prescribed Seroquel (an antipsychotic medication), sertraline (a selective serotonin reuptake inhibitor used to treat depression and panic disorder), trazodone (an antidepressant and sedative medication), and lorazepam (a sedative medication). The facility did not obtain written informed consents for the medications. R61 was prescribed sertraline. The facility obtained verbal consent from R61's decision maker upon R61's admission to the facility on 6/6/23, but did not obtain written consent as of 9/11/23.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide oxygen therapy consistent with professional standards of practice for 1 Resident (R) (R29) of 2 residents reviewed for oxygen therapy. R29's oxygen was not administered based on a licensed nurse assessment. In addition, R29's oxygen saturation was not assessed prior to R29 receiving oxygen.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R17) of 5 residents reviewed for unnecessary medications was monitored for adverse reactions to an antipsychotic medication. R17 was prescribed Seroquel (an antipsychotic medications). The facility did not complete a tardive dyskinesia (TD) (movement disorder characterized by uncontrollable, abnormal, and repetitive movements of the face, torso, and/or other body parts caused by prolonged use of treatments that block dopamine receptors in the brain, such as antipsychotic use) screening assessment to monitor for adverse reactions to the medication. Findings including: The facility's Psychotropic Medication Use policy, with effective date of 11/2012, indicates: 2. Residents undergoing antipsychotic drug therapy receive adequate monitoring for significant side effects of such therapy with emphasis on: [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, and administered for 3 Residents (R) (R17, R22 and R61) of 5 residents reviewed for vaccines. The facility did not review R17's vaccination history or offer R17 the PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®). The facility did not review R22's vaccination history or offer R22 the PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®). The facility did not review R61's vaccination history or offer R61 the PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®).