St Francis Health Services

Based on record review and interview, the facility did not ensure that it did not employ individuals who were found guilty of abuse, neglect, exploitation or mistreatment by failing to conduct a background information disclosure every four years for 1 (Social Services (SS)-G) of 8 facility staff reviewed.This deficient practice has the potential to affect residents who may receive care from SS-G. Findings include:The facility policy titled Abuse, Neglect, and Exploitation with implemented date 3/2018 and revised date 7/15/2022 documents:Policy: it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Screening . potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not ensure medications were stored in accordance with facility policy and procedures for 1 of 1medication room reviewed for medication storage.*On 2/17/2026, at 7:29 AM, Surveyor observed the door to the medication room wide open, and the door propped open with a doorstop. Surveyor noted an open plastic bin with medication packages inside and easily accessible.*On 02/17/2026, at 1:52 PM, Surveyor observed the vaccine refrigerator to read 30 degrees Fahrenheit with frost build up on the inside of refrigerator.Findings:The Facility's policy, titled Medication Storage dated 1/2025, indicates the following, . 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aids) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remained locked when not in use or attended to by persons with authorized access.13. The refrigerator should be kept clean and frost-free. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not complete a significant change in status Minimum Data Set (MDS) assessment for 1 (R30) of 1 resident reviewed for hospice. R30 enrolled in hospice services on 12/26/25. The facility did not complete a Significant Change MDS until 1/26/26. Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual version 1.19.1 dated 10/2024 documents:A Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program . the Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election. R30 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, anxiety, depression, and congestive heart failure. A progress note in R30's electronic health record (EHR) dated 12/29/25 at 9:15 AM documents: [R30] was evaluated by hospice on 12/26/25 and was re-admitted on to services that day. Surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not transmit a discharge assessment within 7 days after completion for 1 (R19) of 1 residents reviewed for late Minimum Data Set (MDS) assessments.*R19 discharged to the hospital on 8/30/2025. The Discharge Return Anticipated (DCRA) MDS assessment dated [DATE] was completed but not submitted.Findings include:1.) R19 was admitted to the facility on [DATE] after hospitalization for acute on chronic neck pain. On 8/30/2025 at 11:10 AM in the progress notes, nursing documented R19 was in bed with complaints of pain to the neck and back. R19's family indicated R19 was not responding as they normally would. R19's vital signs were abnormal, R19 was placed on 3 liters of oxygen and transferred to the hospital.R19's DCRA MDS assessment dated [DATE] was completed. The assessment was not submitted.In an interview on 2/17/2026 at 1:24 PM, Surveyor shared with MDS Licensed Practical Nurse (LPN)-E the concern R19's DCRA assessment dated [DATE] had not been submitted as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility did not ensure residents with hearing impairment received proper treatment and assistive devices to maintain hearing abilities for 1 of 1 (R2) residents reviewed for hearing.* Surveyor observed R2 to be very hard of hearing and not wearing hearing aids. According to R2's most recent audiology consult, and R2's annual Minimum Data Set (MDS), R2 uses hearing aids. The facility failed to ensure R2 received treatment and assistive devices to maintain hearing abilities. Findings include:R2 was admitted to the facility on [DATE] with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) (a progressive lung disease with long term breathing problems).R2's Annual Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15 indicating R2 is cognitively intact, has adequate hearing and uses a hearing aid.On 02/16/2026, at 9:52 AM, Surveyor interviewed R2. Surveyor noted R2 to be very hard of hearing. R2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not always ensure that 1 out of 1 residents ( R6) reviewed for urinary incontinence received the necessary care and services to maintain or restore bladder incontinence. R6 experienced a decline from frequently incontinent of urine to always being incontinent of urine and the facility did not implement interventions in place to help restore R6's urinary continence. This is evidenced by: R6 was admitted to the facility on [DATE] with diagnosis that included Nontraumatic intracerebral hemorrhage, epilepsy, dementia, mood disorder, hypertension, hyperlipidemia and unspecified psychosis.R6's most recent annual MDS ( Minimum Data Set) dated 4/19/25 documents that R6 is frequently incontinent of urine and a trial of a toileting program, prompted voiding or bladder training has not been attempted.R6's Urinary Incontinence and Indwelling Catheter CAA ( Care Area Assessment), dated 4/19/25, was triggered r/t (related to) need for assistance with toileting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R3) of 12 residents observed. During observation of catheter care for R3, certified nursing assistant (CNA)-I did not perform appropriate hand hygiene or wear a gown when enhanced barrier precautions (EBP) were in place for R3.Findings include:The facility's policy titled Enhanced Barrier Precautions with implemented date 3/25/24 and revised date 8/8/24 documents: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs).All staff receive training on enhanced barrier precautions and the definition of high-contact resident care activities upon hire and at least annually . all licensed nursing staff receive training on high-contact care activities and common organisms that require enhanced barrier precautions . An order for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview, review of the Misconduct Incident Report, and facility policy review, the facility failed to ensure that a thorough investigation was documented regarding a potential visitor-to-resident altercation for one (R1) resident out of a sample of 14 residents reveiwed for abuse. Findings include: Review of facility policy titled Abuse, Neglect and Exploitation, revised 07/15/22, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .V. Investigation of Alleged Abuse, Neglect and Exploitation .B. Written procedures for investigations include .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s). Review of the Misconduct Incident Report (final report) provided by the facility dated 05/07/25 revealed On 05/01/25 R1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, and record review, the facility did not maintain an effective infection control program under which it investigates, controls, and prevents infections in the facility. * Total infection rates were not calculated accurately and rates of infection for individual infection types were not calculated. Since infection rates were not calculated it was not possible to analyze the data to determine if there was a rise in the prevalence of infections from month to month with a potential to affect 29 of 29 residents. Findings include: 1.) On 4/9/25, at 1:30 PM., Surveyor interviewed Director of Nursing (DON)-B, who is in charge of the infection control program. DON-B indicated she does not calculate individual rates of infection and will count an infection in more than 1 month if it continues to the next month or is chronic. DON-B indicated she does not separate the facility associated infection from the community based infections. On 4/9/25 the facility's monthly infection rate surveillance summary reports from 10/24 to 3/25 were reviewed and did not include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 4 (R3, R9, R5 and R14) of 4 residents reviewed for hospitalizations received a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. *R3 was transferred to the hospital while residing in the Facility and evidence was not provided that they or their representative were given the required transfer notice information. *R9 was transferred to the hospital while residing in the Facility and evidence was not provided that they or their representative were given the required transfer notice information. *R5 was transferred to the hospital while residing in the Facility and evidence was not provided that they or their representative were given the required transfer notice information. *R14 was transferred to the hospital while residing in the Facility and evidence was not provided that they or their representative were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility did not ensure residents received adequate supervision to prevent accidents for 1 (R22) of 1 residents reviewed for falls. *R22 had three unwitnessed falls that were not thoroughly investigated to determine a root cause and develop interventions that addressed the cause and prevent future falls. Findings include: The facility policy and procedure titled Accidents and Supervision dated 7/14/2022 documents: Policy: The resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility did not ensure food was prepared and served in a form designed to meet individual needs for 1 (R15) of 1 residents reviewed for a mechanically-altered diet. R15 has a puree diet order (level 1), R15 was served a meal tray with a banana cut in half, not pureed as per R15's diet order and meal ticket specification. Findings include: The Facility Diet/Texture Conversion Chart states in part: L1/Puree . follows the regular diet when possible and menu items are pureed . According to the Swallowing Disorder Foundation a Level 1: Pureed Nutrition Therapy diet consists of pureed, homogenous, and cohesive foods. Food should be pudding-like. No coarse textures, raw fruits or vegetables, nuts, and so forth are allowed. The diet recommendation is that fresh bananas be served well-mashed. On 4/9/25, at 08:52 AM, during the kitchen task, Surveyor observed R15's breakfast meal being prepared, the toast, omelet and oatmeal were individually pureed and plated for service. The plate was placed on a food service tray which had half of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the Facility did not ensure food was prepared and served in a sanitary manner. This practice affected 1 of 2 residents with a mechanically-altered diet. R15 was served pureed food that was not brought up to the correct temperature to prevent bacteria growth in the danger zone (below 135 degrees F) The [NAME] was observed changing gloves with no handwashing after gloves were removed, before a new pair of gloves were put on. Findings include: The Facility Policy and Procedure titled, Food: Preparation last revised 9/2017, states in part: Policy Statement All foods are prepared in accordance with FDA (Food and Drug Administration) Food Code. Procedures 1. All staff will practice proper hand washing techniques and glove use. 2. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination . 4. The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that foods are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility did not ensure food was stored, prepared and served under sanitary conditions in 1 of 1 kitchens. This had the potential to affect all 32 Residents. *On 1/30/24 and 1/31/24, during the main kitchen tour, Surveyor observed multiple pieces of kitchen equipment that were not clean. *On 1/31/24, at 7:40 AM, Surveyor observed the robot coupe food processor with splattered food dried on the outside, and crumbs in the crevices. *On 1/30/24 and 1/31/24, Surveyor observed Resident room trays being distributed without lids on the main entree, all cups of liquid, and side dishes were not covered. *The internal dishwashing machine temperature was not being monitored and staff in the dish machine area did not know how to monitor the dishwashing temperatures to ensure dishes & utensils were being sanitized correctly. Findings Include: Surveyor reviewed the facility's General Sanitation of Kitchen policy and procedure and notes the following: .General Sanitation of Kitchen Food and nutrition services staff will maintain the sanitation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.