St. Francisville Nursing and Rehab, LLC

Inspectors wroteBased on interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse by Resident #1 for 1 (#3) of 3 residents reviewed for abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Citation. This deficient practice resulted in an actual harm for Resident #3 on 07/01/2026 when Resident #1 hit Resident #3 causing him to fall to the ground. Resident #3 was sent to a local hospital and a Computed Tomography (CT) Scan revealed a mildly displaced fracture of the intertrochanteric left hip and acute traumatic non-displaced fracture of the right seventh, eighth, and ninth ribs. Resident #3 required emergent surgical intervention on 07/01/2026. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's involuntary discharge notice met the requirement for discharge for 1 (#1) of 3 residents reviewed for transfer and/or discharge by failing to ensure the notice:Was made as soon as practicable before discharge; and Contained the mailing address, email address, and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to consult with a resident's physician when the resident experienced a change in ambulation, assistance with ADLs, and continued pain after a fall for 1 (#100) of 3 residents reviewed for falls. This deficient practice resulted in an actual harm for Resident #100, a cognitively intact resident, beginning on 05/15/2026 when Resident #100 continued to complain of left hip pain after a fall, required increased staff assistance with ADLs, and did not ambulate as normal. Prior to the fall on 05/15/2026, Resident #100 was independently ambulatory and continent. An interview with Resident #100 on 05/18/2026 revealed, after her fall on 05/15/2026, she remained in bed, required perineal care after urinary and bowel elimination, and experienced left hip pain. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide pain management consistent with professional standards of practice and the comprehensive care plan by failing to adequately assess and intervene when a resident experienced pain after a fall for 1 (#100) of 3 residents reviewed for falls. This deficient practice resulted in an actual harm for Resident #100, a cognitively intact resident, beginning on 05/15/2026 when Resident #100 continued to complain of left hip pain after a fall, required increased staff assistance with ADLs, and did not ambulate as normal. An interview with Resident #100 on 05/18/2026 revealed, after her fall on 05/15/2026, she remained in bed and required perineal care after urinary and bowel elimination due to new left hip pain. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident. The facility failed to ensure medications were administered as ordered for 3 (#10, #46, and #100) of 10 residents reviewed for medication administration. Review of the facility's policy titled, Administering Medications with a revision date of 12/2012, revealed the following, in part: Policy: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 3. Medications must be administered in accordance with the orders, including any required time frame. [...]

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure residents were free of significant medication errors for 1 (#46) of 10 residents reviewed for medication administration. The facility failed to ensure Resident #46 received Eliquis and Macrobid as ordered by the Physician.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure each resident received a therapeutic diet as ordered by the physician for 4 (#5, #31, #50 and #87) of 11 residents reviewed for dining. Resident #5Review of Resident #5's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Dementia and Abnormal Weight loss. Review of Resident #5's Current Physician Orders revealed a dietary order for double portions with a start date of 01/22/2026. Resident #31Review of Resident #31's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction and Alzheimer's disease. Review of Resident #31's Current Physician Orders revealed a dietary order for double portions with a start date of 06/03/2024. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food under sanitary conditions. The facility failed to ensure:1. Meat products were stored separate from or below dairy products in the facility's refrigerator; and2. The dishwasher reached 120 consistently during the rinse cycle while washing dishes. This deficient practice had the potential to affect 103 residents who consume food from the facility's kitchen. Review of the facility's policy dated 2001 and titled, Food Receiving and Storage, revealed, the following, in part:Policy Statement: Food shall be received and stored in a manner that complies with safe food handling practices. Refrigerated/Frozen Storage:8. [...]

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff performed proper glove usage and utilized proper Personal Protective Equipment (PPE) while providing care for 3 (#1, #89, and #98) of 4 sampled residents who were on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure resident equipment was maintained in a sanitary manner by failing to ensure wheel chairs were clean for 1 (#99) of 6 residents reviewed in the final sample.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement a resident's comprehensive care plan by failing to ensure PEG tube free water flushes was administered as ordered by the physician for 1 (#1) of 3 residents reviewed for tube feeding.

Inspectors wroteBased on observation, interviews and record review, the facility failed to maintain records in accordance with accepted professional standards and practices for 1 (#5) of 11 residents reviewed for dining. The facility failed to ensure Resident #5's eating ability and performance was documented daily and accurately. Review of the facility's policy dated 2001 and titled, Charting and Documentation, revealed the following, in part:Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation3. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received incontinence care timely to maintain good personal hygiene for 2 (#2 and #4) of 6 residents reviewed for incontinence.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide sufficient nursing staff to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care by failing to provide incontinence care timely for 1 (#4) of 6 residents reviewed for incontinence.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's right to be free from physical abuse and psychosocial harm for 1 (#75) of 2 (#46 and #75) residents reviewed for abuse. The facility failed to ensure Resident #75 was free from physical abuse and psychosocial harm by Resident #46. This deficient practice resulted in a psychosocial harm on 03/03/2025 at 12:12 p.m. when Resident #75 reported to S2DON she did not feel safe in her home after an incident where Resident #46 hit her on the head. Resident #75 did not want to leave her room on 03/04/2025 because she was afraid of Resident #46. Resident #75 reported to Resident #87 that she was being scared when Resident #46 returned from the hospital on [DATE]. [...]

Inspectors wroteBased on record review and interview the facility failed to submit accurate payroll information for direct care staffing as required.

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident assessments accurately reflected the residents' status. The facility failed to ensure staff accurately coded the diagnoses of Post-Traumatic Stress Disorder for 2 of 2 (#40 and #87) residents reviewed for PTSD.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by failing to ensure a resident received an appointment with an ENT specialist for 1 (#34) of 2 (#34 and #51) residents reviewed for hospitalization. Review of Resident #34's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Traumatic Subdural Hemorrhage and Dysphonia. Review of Resident #34's physician orders revealed in part, the following: 02/18/2025 please refer to a private physician for evaluation of persistent hoarseness. Review of Resident #34's Nurse Practitioner Progress notes revealed in part, the following: 03/05/2025 Referral toa private physician was denied for evaluation. Will refer to a local ENT. An interview was conducted with S10WC on 04/16/2025 at 12:17 p.m. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents who are trauma survivors received trauma-informed care and services in accordance with professional standards of practice for 2 of 2 (#40 and #87) residents reviewed with a diagnosis of Post-Traumatic Stress Disorder (PTSD).

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. A multi dose vial of insulin was dated upon opening; and 2. Medication Cart #3 was kept locked when not under direct observation of authorized staff. This deficient practice had the ability to affect any of the 105 residents who received medications in the facility.

Inspectors wroteBased on observations, and interviews, the facility failed to store, distribute and serve food in sanitary conditions in accordance with professional standards for food service safety. The facility failed to ensure: 1. Opened food was properly labeled and dated in the refrigerator and freezer of the facility's kitchen; 2. Staff properly sanitized food thermometer when checking food temperatures to prevent cross contamination; 3. Ground beef was served at safe temperatures; and 4. The Air Conditioner (AC) in the kitchen remained in sanitary condition. This deficient practice has the potential to affect 104 residents who were served meals from the facility's kitchen.

Inspectors wroteBased on observations and interviews the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1(#68) of 23 residents reviewed in the final sample. The facility failed to ensure Resident #68's urinary drainage bag remained covered in order to maintain his dignity.

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to ensure a referral was made to an oral surgeon as ordered for 1 of 1 (#92) resident reviewed for dental services. This deficient practice had the potential to affect any of the 105 residents residing at the facility.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 2 of 2 (#77 and #86) resident's reviewed for perineal care. The facility failed to ensure staff performed hand hygiene and proper glove use for Resident #77 and Resident #86 during perineal care.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure each resident had the right to be free from physical abuse by another resident for 2 (#1 and #3) of 3 (#1, #2, and #3) sampled residents reviewed for abuse. The facility failed to ensure Resident #1 and Resident #3 were free from physical abuse by Resident #2. This deficient practice resulted in an actual harm on 11/22/2024, at 3:56 p.m., when Resident #2, a resident know with physically abusive behaviors towards other residents, physically punched Resident #1 in the face and neck multiple times resulting in Resident #1 being evaluated and treated at a local hospital with diagnostic testing. Resident #1 experienced physical pain, facial swelling, and bloody drainage from the nose as a result of this incident. [...]

Inspectors wroteBased on record review and interviews, the facility failed to implement the comprehensive person centered care plan for 1 (#2) of 3 (#1, #2, and #3) residents reviewed. The facility failed to maintain line of sight supervision per Resident #2's care plan. This deficient practice resulted in an actual harm on 11/22/2024 at 3:56 p.m., when S3LPN noticed S5CNA failed to maintain line of sight supervision per the care plan on Resident #2, a resident with known physical behaviors towards other residents. During this time, Resident #2 physically assaulted Resident #1. Resident #1 was evaluated and treated at a local hospital with diagnostic testing. Resident #1 experienced physical pain, facial swelling, and bloody drainage from the nose as a result of this incident. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a cognitively impaired resident received treatment and care in accordance with professional standards of practice for 1 (#2) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure: 1. S5LPN transcribed new telephone orders for Tylenol and an X-Ray for Resident #2; 2. S5LPN implemented a new telephone order for an X-Ray for Resident #2 after a fall and complaint of pain; and 3. S5LPN communicated Resident #2's change in status, fall, or new orders of Tylenol and an X-Ray to oncoming staff prior to leaving the facility at the end of her shift. This deficient practice resulted in an actual harm for Resident #2, a severely cognitively impaired resident, beginning on 04/01/2024 at 6:30 a.m. when S5LPN left the facility without communicating Resident #2's fall and new X-Ray order to any other staff. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's medical record was maintained accurately and systematically in accordance with accepted professional standards and practices by failing to transcribe and document administration of Tylenol on the MAR for 1 (#2) of 3 (#1, #2, and #3) sampled residents.

Inspectors wroteBased on interviews and observations, the facility failed to ensure that residents had a clean and safe environment for 1 (#36) of 2 (#36 and #65) residents reviewed for environment. The facility failed to ensure: 1. The front face covering for Resident #36's air condition/heater unit was properly secured; and 2. Resident #36's nightstand was not missing the third drawer. Findings On 03/18/2024 at 9:23 a.m., an observation was made of Resident #36's room. The air conditioner's front cover was detached and laying on the floor in front of the unit by the window. The night stand on the left side of his bed was missing the 3rd drawer. On 03/19/2024 at 8:08 a.m., an observation was made of Resident #36's room. The air conditioner's front cover was detached and laying on the floor in front of the unit by the window. The night stand on the left side of his bed was missing the 3rd drawer. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents' assessments accurately reflected the residents' status by failing to ensure a resident's Minimum Data Set was accurately coded for PASRR (Pre-admission Screening and Resident Review) for 2 (#27 and #52) of 4 (#13, #27, #42, and #52,) sampled residents reviewed for PASRR.

Inspectors wroteBased on interviews and record review the facility failed to developed a comprehensive person-centered plan of care for 1 (#59) of 25 residents reviewed in the final sample. The facility failed to ensure interventions related to hydration for Resident #59 were reflected in the plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the required nurse staffing information on a daily basis.