Mount St Francis Nursing Center

In the surveyor’s words

From the most serious findings on record at Mount St Francis Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 29, 2022

  Based on record review and interviews, the facility failed to provide one (#1) of three residents, out of nine sample residents adequate supervision and an environment as free from accident hazards as possible, contributing to an accident involving harm. On [DATE] at approximately 7:30 p.m., the activities director (AD) and the activities assistant (AA) assisted Resident #1 on to the facility's transportation bus. The facility failed to ensure Resident #1 was securely fastened in her wheelchair during the evening bus ride to look at holiday lights. During the holiday light tour, Resident #1 reported she felt loose in her chair. The AD reported she stopped the bus and redid Resident #1's wheelchair tie downs and determined Resident #1 was fastened appropriately. […]

• No harm, potential for more than minimal, widespreadF882Nov 30, 2023

  Based on interviews and record review, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified ICP involved with the facility's infection prevention and control program. Findings include: I. Professional references The Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 5/8/23 and retrieved on 12/11/23, from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html read in… […]

• No harm, potential for more than minimal, widespreadF812Aug 17, 2023

  Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner to prevent food-borne illness. Specifically, the facility failed to ensure: -Holding temperatures were appropriate; -Moisture was not between stacked pans; -Appropriate sanitation of utensils, lids and thermometers; and, -Appropriate sanitation of food coolers on resident floors. Findings include: I. Holding temperatures A. Professional reference The Food and Drug Administration (FDA) Food Code (2019) p. 441, When food is held, cooled, and reheated in a food establishment, there is an increased risk from contamination caused by personnel, equipment, procedures, or other factors. […]

• No harm, potential for more than minimal, patternF730Mar 6, 2025

  Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for three of three certified nurse aides (CNA). Specifically, the facility to complete regular in-service education based on the outcome of the annual performance reviews for CNA #8, CNA #9 and CNA #10. Findings include: I. Facility policy and procedure The Performance Management Procedure, reviewed 6/1/2020, was provided by the director of quality and safety (DQS) on 3/6/25 at 2:38 p.m. It read in pertinent part, The facility expects its managers and their direct reports to participate in the annual performance review process and discussions. […]

• No harm, potential for more than minimal, patternF880Nov 30, 2023

  Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for one of three floors. Specifically, the facility failed to: -Ensure proper personal protective equipment (PPE) was utilized in COVID-19 positive rooms; -Ensure residents were provided with an opportunity to participate in hand hygiene before meals; -Ensure shared equipment was properly disinfected between use; -Ensure staff followed proper hand hygiene procedures when moving from task to task; and, -Provide accurate isolation precautions, including isolation signage and assure the resident doors remained closed. Findings include: I. […]