CHI Health St. Francis

In the surveyor’s words

From the most serious findings on record at CHI Health St. Francis, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF729Mar 20, 2025

  Licensure Reference Number 175 NAC 12-006.04(A)(iii)(2)(a) The facility failed to verify that the Central Registry (Maintains all reports of child abuse and neglect opened for investigation, classified as either Court Substantiated or Agency Substantiated) check was completed for 1 out of 10 Nursing Assistant (NA-A) sampled staff employees files. This had the potential to affect all 15 residents in the facility. Findings are: A record review of NA-A employee file revealed that the Nebraska Central Registry (Maintains all reports of child abuse and neglect opened for investigation, classified as either Court Substantiated or Agency Substantiated) with the following reason: -Notary needed A record review of NA-A work schedule revealed that NA-A worked the floor on: 3/13/25 3/14/25 3/15/25… […]

• No harm, potential for more than minimal, widespreadF812Feb 1, 2024

  Licensure Reference Number 175 NAC 12.006.11E Based on observation, interview, and record review the facility failed to ensure items stored in the facility's refrigerators and freezers were sealed, labeled, and dated, ensure expired items were discarded, ensure kitchen staff performed handwashing for at least 20 seconds, and failed to ensure the temperature of the food was taken after being reheated in the microwave to prevent the potential for foodborne illness, and failed to ensure the thermometer probe was sanitized before use and between food items when the temperature was taken of the prepared food to prevent cross contamination. This had the potential to affect 15 of the 16 residents that consumed food from the kitchen. […]

• No harm, potential for more than minimal, widespreadF923Mar 13, 2023

  Licensure Reference Number 175NAC 12-007.04D Based on observations, record review, and interview the facility failed to ensure that bathroom exhaust vent fans were operational in 16 of 16 occupied rooms. This affected all facility residents. The facility census was 16. Findings are: Record review of the facility Admission Agreement Resident Rights dated 2016 revealed that the nursing facility must provide a safe, clean, comfortable, and homelike environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation on 3/7/23 at 9:36 AM in room [ROOM NUMBER] revealed that the bathroom vent fan would not suck up a 1 ply square of toilet paper (indicating that the vent was not operating). […]

• No harm, potential for more than minimal, patternF655Mar 13, 2023

  Licensure Reference Number 175NAC 12-006.09C1a Based on record review and interview the facility failed to ensure that the resident /resident representative received a written summary of the preliminary care plan (either the baseline or the comprehensive care plan) (a written initial plan of care required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) as required for 5 residents (Residents 66, 11, 69, 5, and 13) of 5 residents reviewed. This prevented the resident/resident representative from identifying additional areas of care required. […]

• No harm, potential for more than minimal, patternF758Nov 15, 2021

  Licensure Reference Number 175NAC 12-006.12B Based on record review and interview, the facility failed to ensure that Gradual Dose Reductions (GDRs) (the periodic physician review of the amount of a [CONDITION(S)] medication that a resident is receiving to consider a decrease in the amount of the medication) were attempted for [CONDITION(S)] medications (any medication that affects behavior, mood, thoughts, or perception) as required for 2 residents (Residents 9 and 6) of 5 residents reviewed. This had the potential to prevent residents from being free from the use of unnecessary medications. […]