St. Francois Manor

Inspectors wroteBased on record review and interview the facility failed to notify the resident representative of a change in the resident's medication regimen for one resident (Resident #1) of nine sampled residents. The facility census was 85. Review of the facility's policy titled, Management of Psychotropic Medications and Unnecessary Medications, dated 04/2025, showed staff were directed to do the following: - Informed consent: The process in which a resident, or their legal representative is provided with information about their medication regimen, including risk, benefits, and alternatives and is given the opportunity to accept or refuse the prescribed treatment. 1. Review of Resident #1's quarterly Multiple Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 01/09/26 showed:- Independent in cognitive skills for daily decision-making; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences for one resident (Resident #3) of 11 sampled residents. The facility census was 86. The facility failed to provide policies and procedures for following through on physician's referrals and physician's orders. The facility failed to provide policies and procedures regarding obtaining informed consent prior to receiving a medication increase or changes in the resident's medication regimen. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's physician or guardian after a change in the resident's condition for one resident (Resident #1) out of three sampled residents. The facility census was 89. Review of the facility's policy titled, Condition Change, Resident, undated, showed:- The purpose of these guidelines is to observe, record, and report any condition change to the attending physician so that proper treatment can be implemented;- Notify resident's responsible party, notify physician of condition change, need for treatment orders, and/or medication order. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders when two follow up appointments were not made on admission and parameters for intermittent urinary catheterization were not implemented and followed for one resident (Resident #1) out of five sampled residents. The facility census was 89. Review of the facility's policy titled, Physician Orders, undated, showed: - Specify why a urinary catheter (a thin, flexible, rubber or plastic tube that drains urine from the bladder) is ordered for as needed;- Specify the size of the catheter and the frequency of change;- Did not address following physician's orders. The facility did not provide a policy for intermittent catheterization or making appointments. [...]

Inspectors wroteBased on observation and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility's census was 78. The facility did not provide a policy regarding freezer temperatures or freezer temperature logs. 1. Observations on 06/11/25 at 1:08 P.M. and 06/12/25 at 3:14 P.M. of the walk-in refrigerator showed: - One bag of block cheese not dated or labeled; - One box of lunch meat not dated; - Three boxes of vegetables not dated. Observation on 06/13/25 at 9:35 A.M. of the walk-in refrigerator showed: - One bag of block cheese not dated or labeled; - One box of lunch meat not dated; - Multiple cases of food not dated; - Multiple bags of vegetables not dated. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post, in a form and manner accessible to the residents and resident representatives, the required telephone number to the Department of Health and Senior Services (DHSS) hotline (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SSA). The facility's census was 78. The facility did not provide a policy regarding the posting of DHSS hotline number and SSA information. Observation of the facility from 06/10/25 through 06/13/25 showed: - The facility did not post the name, address and toll free telephone number for the DHSS Abuse and Neglect Hotline or the SSA information in a form and manner accessible to residents or visitors. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess two residents (Residents #10 and #57) out of two sampled residents for the use of side rails and to provide ongoing monitoring, supervision and routine maintenance of the beds with the side rails in use. The facility's census was 78. The facility failed to provide a policy regarding side rails. 1. Review of Resident #10's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 04/18/25, showed: - Cognition intact; - Independent with bed mobility; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. This deficiency had the potential to affect all residents. The facility's census was 78. The facility did not provide an RN coverage policy. Review of the Nurse Staffing Sheets for March 1, 2025 - June 9, 2025 showed: - No RN scheduled for 05/18/25; - No RN scheduled for 06/01/25; - No RN scheduled for two days out of 101 days. Review of the Nursing Schedule for March 1, 2025 - June 9, 2025 showed: - No RN scheduled for 05/18/25; - No RN scheduled for 06/01/25; - No RN scheduled for two days out of 101 days. During an interview on 06/13/25 at 12:16 P.M., the Administrator and Director of Nursing (DON) said they would expect the facility to have RN coverage for at least eight hours a day for seven days a week.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the nurse staffing data with all the required components in a clear and readable format. The facility's census was 78. The facility did not provide a policy regarding posting of nurse staffing data. Observations of the nurse staffing information posted on the wall across from the nurse's station showed: - On 06/10/25 at 2:40 P.M., the posted nurse staffing information, dated 06/09/25, with no information for 06/10/25; - On 06/11/25 at 2:02 P.M., the posted nurse staffing information, dated 06/10/25, with no information for 06/11/25; - On 06/12/25 at 2:40 P.M., the posted nurse staffing information, dated 06/11/25, with no information for 06/12/25; - On 06/13/25 at 8:02 A.M., the posted nurse staffing information, dated 06/11/25, with no information for 06/13/25. [...]

Inspectors wroteBased on observation, interview, and record review of two medication rooms and two medication carts, the facility failed to ensure medications and biologicals were labeled in accordance with currently accepted practices for one medication cart out of two sampled medication carts and one medication room out of two sampled medication rooms. This had the potential to affect all residents. The facility's census was 78. Review of the facility's policy titled, Storage of Medications, undated, showed: - No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use; - All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. 1. Observation of the 600 Hall Medication Cart on 06/13/25 at 8:58 A.M. showed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, and side rails for possible entrapment as part of a regular maintenance program for two residents (Resident #10 and #57) out of two sampled residents. The facility's census was 78. The facility failed to provide a policy regarding bed frame, mattress, and side rail inspections. 1. Review of Resident #10's medical record showed: - No maintenance inspections/assessments for possible entrapment for the side rails. Observations on 06/10/25 at 10:45 A.M. and 06/12/25 at 3:14 P.M. showed: - The resident lay in bed with a 1/4 U-shaped side rail on the upper right side of the bed. 2. Review of Resident #57's medical record showed: - No maintenance inspections/assessments for possible entrapment for the side rails. Observations on 06/10/25 at 11:30 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders regarding medication for one resident (Resident #1) out of three sampled residents. The census was 80. Review of the facility's policy titled Medication Administration Guidelines dated March, 2015, showed: - It is the purpose of this facility that the residents receive their medications on a timely basis and in accordance with established policies. Drug administration shall be delivered as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a privacy curtain to maintain privacy for two residents (Resident #3 and #10) out of 18 sampled residents. The facility census was 77. 1. Observation on 06/10/24 at 11:15 A.M., showed: - Resident #3 lay in his/her bed; - Resident #10 sat on his/her bed and listened to music; - No privacy curtain between the beds. 2. Observation on 06/11/24 at 9:03 A.M. showed: - Resident #3 lay in his/her bed and folded clothes; - Resident #10 opened the bedroom door, entered the room, and sat on his/her bed; - No privacy curtain between the beds. During an interview on 06/11/24 at 9:03 A.M., Resident # 3 said he/she wanted more privacy. He/She liked the roommate but did not need him/her knowing everything he/she did at all the time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 77. Review of facility's policy titled, Deep Clean Schedule, undated, showed: - A deep clean should be performed every four-six weeks; - The housekeeping supervisor must develop a deep clean schedule. 1. Observations of room [ROOM NUMBER] on 06/10/24 at 10:25 A.M., and 06/13/24 at 11:12 A.M., showed a three inch (in.) circular hole next to the bathroom door. 2. Observation of room [ROOM NUMBER] on 06/10/24 at 11:00 A.M., showed: - A three inch hole in ceiling above the bed next to the window; - No door on the closet; - The dresser missing the top drawer; - The room walls near the bathroom with a brown film and small brown dots; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for six residents (Resident #3, #17, #27, #33, #41 and #51) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of six sampled residents. The facility's census was 77. The facility did not provide a policy regarding PTSD. 1. Review of Resident #3's medical record showed: - An admission date of 05/09/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement procedures to ensure medications were accurately administered, documented, disposed of and reconciled for one resident (Resident #3) out of 18 sampled residents and for one resident (Resident #8) outside the sample. The facility census was 77. Review of the facility's policy titled, Medication Monitoring and Management, revised January 2018, showed: - A new medication order is evaluated for dose, route of administration, duration, monitoring in agreement with current clinical practice, guidelines, or manufacturer's specifications for use, a written diagnosis supports each medication, and the prescriber documents the clinical rationale for using a medication outside the stated guidelines; - The resident is evaluated before initiating, withdrawing, or withholding medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted practices. This had the potential to affect all residents. The facility census was 77. Review of the facility's policy titled, Medication Storage in the Facility, revised January 2018, showed: - Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier; - Outdated or deteriorated medications are immediately removed from the inventory, disposed of according to procedures for medication disposal, and reordered from pharmacy if a current order exists; - Medication storage conditions are monitored on a quarterly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 71. Record Review of the facility's policy titled, Can Opener, showed: - Immediately after use remove the stand from base; - Wash blade with a brush in hot detergent solution; - Run through the dishwasher and air dry; - Wash base with hot detergent solution, use scrub brush, rinse with clear water and let dry; - Re-assemble the stand in base; - Keep an extra blade on hand at all times. Record Review of the facility's policy titled, Cleaning Floors, showed: - Kitchen floor maintenance will be done after each meal, spills need to be mopped up immediately; - Place caution signs around all areas that will be wet; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage dumpsters and trash receptacles were covered for four of four days of observation. The facility census was 71. 1. Observation of the dumpster area on 1/09/23 at 12:00 P.M. showed the following: - Two, 8 yd. (yard) dumpsters filled with clear trash bags that were full of refuse; - One dumpster with lids entirely opened. 2. Observation of the dumpster area on 1/09/23 at 3:26 P.M. showed the following: - Two 8 yd. dumpsters with lids entirely opened. 3. Observation of the dumpster area on 1/10/23 at 8:16 A.M. showed the following: - Two 8 yd. dumpsters partially filled with lids entirely opened on each side. 4. Observations of the dumpster area on 1/11/23 at 8:00 A.M. showed the following: - Two 8 yd. dumpsters with lids entirely opened; - One 8 yd. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents at the facility. The facility census was 71. Record Review of the facility's Resident Council minutes, dated 10/07/23, 11/4/23, and 12/02/22, showed: - Residents were concerned that toilets, drains, sinks, and unit bathroom (shower room) needed cleaned; - Residents were concerned that rooms, bathrooms, and the dining room needed cleaned; - Residents were concerned that rooms are not cleaned properly. Observation of the exterior of the door to the ice machine on 300 hall on 1/09/23 at 10:39 A.M., 12:53 P.M., 2:46 P.M., 3:16 P.M. and on 1/12/23 at 12:10 P.M. showed: [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide appropriate treatment and services to maintain or improve the highest level of function for one resident (Resident #72) out of 22 sampled residents. The facility census was 71. Record review of Resident #72's medical record showed: - An admission date of 11/16/22; - Diagnoses of Unspecified fracture of right femur, initial encounter for closed fracture (Admission), Chronic instability of knee, right knee. Record review of an After Visit Summary for Resident #72 dated 11/22/22 showed a physician's order for physical therapy. Record review of an After Visit Summary for Resident #72 dated 12/15/22 showed a physician's order for physical therapy on a regular basis ideally with emphasis on gait training quad strengthening endurance range of motion. [...]