St Francis Center for Rehabilitation & Healthcare

In the surveyor’s words

From the most serious findings on record at St Francis Center for Rehabilitation & Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 15, 2022

  Based on review of facility policies, review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure that one of 20 residents was free from physical abuse from a nursing staff and that the resident was protected from further physical abuse. (Resident R1) This failure resulted in an immediate jeopardy situation for Resident R1 who was slapped across the face by a nursing staff. The facility failed to suspend the perpetrator from employment at the time of the incident and remained in the facility for the duration of the shift placing six additional residents (Resident 12, Resident 13, Resident 14, Resident R15, Resident R16, Resident R17) at risk for physical abuse. […]

• No harm, potential for more than minimal, patternF806Jul 18, 2025

  Facility failed residents with food preferences.Based on interviews with residents, observations of the food service and a test tray evaluation, interviews with dietary staff, reviews of policies and procedures and reviews of resident council and food committee meeting minutes, it was determined that each resident was not receiving foods and drinks to accommodate their individualized preferences. Appealing food and drink options of similar nutritive value were not being planned and provided on facility menus. (Residents R58, R47, R164, R145, R 207, R208, R220, R77, R117, R196, R64, R194, R144, R219, R86, R50, R234 and R115). […]

• No harm, potential for more than minimal, patternF842Apr 24, 2024

  Based on clinical record review and interview with staff, it was determined that the facility did not maintain complete and accurate medical records for eight of 10 records reviewed (Resident R2, R3, R4, R5, R6, R7, R8, R10). Findings include: Review of the April 2024 Treatment Administration Record (TAR) documentation for resident R2 revealed that an order to Check placement of [NAME]-chip (a wearable tracking device designed to prevent cognitively impaired residents from wandering from designated, staff monitored areas) to right ankle .every shift for elopement, ordered on March 21, 2024, had not been signed off as completed on day shift on April 16 and 22, on evening shift on April 1-3, 5-8, 10-12, 15-17, 19, and 20, or on night shift on April 1, 5, 7-10, 12, 15, 17, and 22. […]

• No harm, potential for more than minimal, patternF925Dec 1, 2023

  Based on observations, interviews, and a review of facility documentation, it was determined that the facility was not maintaining an effective pest control program. Findings include: Observations during the initial tour of the 2 Main nursing on November 28, 2023, at 11:35 a.m. in room [ROOM NUMBER], bed A revealed Resident R93 laying in bed with a fly buzzing around his head while attempting to interview him. Observations during the initial tour of the 2 Main nursing on November 28, 2023, at 11:45 a.m. in room [ROOM NUMBER], bed B revealed Resident R23 sitting up in her bed waving her hand at a fly buzzing around her. An interview on November 28, 2023, at 11:45 a.m. […]

• No harm, potential for more than minimal, patternF919Dec 7, 2022

  Based on observations of the physical environment and communication system, reviews of policies and procedures, clinical record reviews, and interviews with staff and residents it was determined that the resident call system was not fully functioning on one of seven nursing units (Two Main Nursing Unit - Residents: R1, R7, R8 and R11) Findings include: A review of the policy titled call bell system revealed that the facility uses a call bell system to call for staff assistance. The policy also said that the call bell system would be answered by staff who were in the vicinity of the call bell alarm and light. […]