St Frances NSG & Rehab Center

In the surveyor’s words

From the most serious findings on record at St Frances NSG & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF684Mar 16, 2022

  Based on interview and record the facility failed to ensure physician ordered wound care treatments were administered in accordance with professional standards of practice for 10 (#2, #5, #6, #7, #9, #10, #11, #12, #13, and #14) of 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14) sampled resident who received wound care. The deficient practice resulted in an Immediate Jeopardy situation on [DATE] when S3RN/DON allowed S10CNA to perform complex wound care for Residents #2 and #5, PEG tube care for Residents #9, #10, #11, #12, #13 and #14, and treatment to skin tears for Resident #7. As of [DATE], the facility has failed to re-educate/retrain staff regarding respective job responsibilities/duties. […]

• Immediate jeopardy, patternF835Mar 16, 2022

  Based on interview and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, by failing to ensure wound care was performed in accordance with professional standards of practice for 10 (#2, #5, #6, #7, #9, #10, #11, #12, #13 and #14) of 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, 312, #13 and #14) sampled residents. This deficient practice resulted in an Immediate Jeopardy situation on 02/16/2022 when S3RN/DON allowed S10CNA to perform complex wound care for Residents #2 and #5, PEG Tube care for Residents #9, #10, #11, #12, #13 and #14, and treatment to skin tears for Resident #7. […]

• Immediate jeopardy, isolatedF689Nov 6, 2024

  Based on observation, interview and record review, the facility failed to ensure Resident #2, who had been assessed to be at high risk for elopement, received adequate supervision to prevent the resident from eloping from the facility, for 1 (#2) of 4 (#1, #2, #3, and #4) residents reviewed for elopement. Findings: This deficient practice resulted in an immediate jeopardy situation on 10/26/2024 at 1:55 a.m., when Resident #2, who was moderately impaired cognitively, had a history of exit seeking behaviors, had been identified as a high elopement risk, and wore a wanderguard bracelet, exited the facility through the front door without staff knowledge. […]

• Immediate jeopardy, isolatedF835Nov 6, 2024

  Based on interview on record review, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 (#2) of 4 (#1, #2, #3, and #4) residents reviewed for elopement. The Administration failed to have an effective system in place to respond when Resident #2, who was assessed to be at risk for elopement, eloped from the facility on 10/26/2024 at 1:55 a.m. The likelihood continued for the remaining 3 residents (#1, #3 and #4), who were assessed as being at risk for elopement. […]

• No harm, potential for more than minimal, widespreadF576Apr 30, 2025

  Based on interview and record review the facility failed to ensure residents received mail on Saturdays. This has the potential to affect all 73 residents residing in the facility. Findings: Review of an undated facility policy on 04/29/2025 at 11:45 a.m. titled, Resident Right to Privacy in Communication revealed the following in part .The facility will honor the resident's right to privacy in written communication including the right to: 1.Send and promptly receive mail that is unopened. 1. The social service designee, or another designated staff member, will ensure each resident receives any mail addressed to that particular resident promptly. On 04/28/2025 at 1:30 p.m., the Resident Council Meeting was conducted and revealed the residents did not receive mail on Saturdays. […]