St. Francis Nursing Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 resident hall (Hall 200) of 4 resident halls reviewed, in that:Potentially harmful cleaning materials were unsecured in resident Hall 200. This deficient practice could result in an unsafe environment for residents, staff, and the public.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to formulate an advance directive for one (Resident 40) of twenty-five residents reviewed, in that:Resident #40's OOH-DNR was not fully signed by Witness #1 and was therefore invalid. This deficient practice could result in residents' end of life wishes being unknown or dishonored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 6 residents (Residents #14, and #78) reviewed for infection control, in that: 1. The facility failed to ensure CNA A sanitize her hands while providing incontinent care for Resident #14 2. The facility failed to ensure Medication Aide B did not touch medications without wearing gloves while administering medications to Resident #78. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for two of three refuse containers (Dumpster #1 and Dumpster #2 used for recyclable refuse) on the loading dock. The facility failed to ensure the doors to Dumpster #1 and Dumpster #2 were closed. This deficient practice could place residents at risk for illness from exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure appropriate and timely care when Resident #1 had a fall on 4/16/2025 and was diagnosis with a fractured C1 vertebrae, traumatic subarachnoid hemorrhage, scalp laceration requiring repair and hematoma/contusion. 2. The facility failed to ensure LVN B did not move Resident #1 with a mechanical lift after a fall on 04/16/2025. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1), reviewed for quality of care. The facility failed to supervise Resident #1 when she was left unattended during care while CNA A retrieved supplies and resulted in a fall with a head injury, scalp laceration, hematoma/contusion to the forehead/scalp, traumatic subarachnoid hemorrhage and fracture to the C-1 vertebrae of her neck. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/23/25. The noncompliance began on 4/16/2025 and ended on 4/22/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of accidents, and could result in serious injury, harm, impairment, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to store, label and date food items properly in the walk-in cooler, freezer, and dry storage room. 2. The facility failed to store a dented can in a separate location in the dry storage room. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption of residents' food items for 4 of 5 resident refrigerators (refrigerators in resident Rooms 115, 208, 213, and 215) reviewed for personal food policy, in that: 1. The personal refrigerators in three residents' Rooms (115, 208, and 215) contained food items which were unlabeled and undated. 2. The internal temperature of the refrigerator on resident room [ROOM NUMBER] exceeded 41 degrees Fahrenheit. These deficient practices could place residents at risk of foodborne illness due to consuming foods which were spoiled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 facility reviewed for effective pest control, in that: The facility failed to ensure the facility was free from live rodents. This deficient practice could place residents at risk of remaining in an environment that was not free of pests and rodents.

Inspectors wroteBased on Observation, Interview, and Record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 5 (Residents #3 and #49) reviewed for resident rights, in that: The facility failed to ensure Resident #3's and Resident #49's call light was within reach. This failure could place residents at risk of not achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #3) reviewed for privacy, in that: The facility failed to ensure MA D locked the computer, which exposed Resident #3's morning medication list after she walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, including tracheostomy care and tracheal suctioning was provided such care, consistent with professional standards of practice, for 2 of 3 residents (Residents #6 and #23) reviewed for respiratory care in that: The facility failed to ensure Residents #6 and #23's, oxygen tubing was dated. This deficient practice could place residents at risk for an increase in respiratory complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days , except if the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for 1 of 3 residents (Resident #41) reviewed for pharmacy services, in that: The facility failed to ensure Resident #41 had a stop date for PRN Xanax 0.25 mg (a medicine used to treat the symptoms of anxiety). This failure could place residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 1 resident (Resident #6) reviewed for infection control, in that: The facility failed to ensure LVN C changed her gloves when moving from a dirty to clean task and failed to use appropriate hand hygiene between glove changes when she provided wound care to Resident #6. This deficient practice could place residents at risk for infection .

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to post information on a daily basis regarding the total number of the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift for registered nurses, licensed practical nurses or licensed vocational nurses, certified nurses aides and resident census for 1 of 1 facility reviewed for posting. The facility failed to include the actual hours worked for the nursing staff on the nursing daily staff posting This deficient practice could place residents at risk or missed or inadequate care.

Inspectors wroteBased on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder or related condition for level II resident review upon a significant change in status assessment for 1 of 1 Resident (Resident #2) reviewed for PASARR eligibility, in that: The facility failed to refer Resident #2 for a PASARR level II evaluation after being diagnosed with Major Depressive Disorder (MDD) and Bipolar Disorder. This deficient practice could affect residents with new mental illness diagnoses and it could result in residents not receiving services as needed.