St Francis Health Services

In the surveyor’s words

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

• Actual harm, isolatedF686Feb 18, 2026

  Based on observation, interview and record review, the Facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R43 & R4) of 3 Residents reviewed for pressure injuries. *R43 is dependent for all cares, requires substantial/maximal assistance with bed mobility and is at risk for developing pressure injuries. On 12/24/2025, the Facility implemented a care plan for R43's risk for pressure injuries with interventions not supportive of R43's needs. […]

• No harm, potential for more than minimal, widespreadF880Apr 10, 2025

  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. […]

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

  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. […]

• No harm, potential for more than minimal, widespreadF880Sep 20, 2021

  Based on observations, interviews and record review, the facility did not maintain an effective infection prevention and control program to prevent and control the spread of infections such as COVID-19. The facility did not ensure staff wore appropriate and correct personal protective equipment (PPE) when working in Resident care areas, including the use of N95's for Residents in isolation. Additionally upon leaving residents in isolation, staff did not complete appropriate hand hygiene. This deficient practice has the ability to affect all of the 33 residents who reside within the facility as facility staff float the building. *R282 was in droplet and contact precautions/isolation during the survey process due to not being vaccinated. […]

• No harm, potential for more than minimal, patternF607Feb 18, 2026

  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… […]