St Francis Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Jan 27, 2022

  Based on observation, interview, and record review, the facility failed to follow their policies and procedures to mitigate the spread of COVID-19 (a respiratory virus that can cause mild to serious respiratory illness) when resident room doors were left open in the COVID-19 positive wing with no physical barrier between COVID-19 positive and COVID-19 negative residents and when an employee did not wear personal protective equipment (PPE, equipment worn to minimize exposure to hazards) before entering a room requiring transmission-based precautions (infection-control precautions in health care). These deficient practices had the potential to spread infection among residents and for Residents 3, 16, 48, 50, 51, 71, 72, 77, 80, 85, 96, 98. 99. […]

• No harm, potential for more than minimal, patternF609Apr 10, 2026

  Cross Reference F607, F610 Based on interview and record review, the facility failed to report allegations of abuse involving one of 18 sampled residents (Resident 27) to the appropriate agencies including the California Department of Public Health (CDPH), within the required timeframe. This failure to report allegations of abuse placed Resident 27 at risk of further abuse. A review of Resident 27's Face Sheet (information containing contact details, brief medical history at-a-glance) indicated Resident 27 was admitted to the facility on [DATE] with diagnoses which hemiplegia and hemiparesis due to a stroke (hemiplegia means paralysis on one side of the body and hemiparesis means weakness in one side of the body).Resident 27's Minimum Data Set (MDS, a standardized assessment tool) dated… […]

• No harm, potential for more than minimal, patternF610Apr 10, 2026

  Based on interview and record review, the facility did not report Resident 27's alleged abuse investigation results to the State Agency.This failure placed Resident 27 at risk for further harm and abuse.A review of Resident 27's Face Sheet (information containing contact details, brief medical history at-a-glance) indicated Resident 27 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis due to a stroke (hemiplegia means paralysis on one side of the body and hemiparesis means weakness in one side of the body).During a review of Resident 27's Minimum Data Set (MDS, a standardized assessment tool), dated 3/20/26, it indicated that Resident 27 had a Brief Interview for Mental Status (BIMS, an assessment tool for cognition) score of 8, reflective of… […]

• No harm, potential for more than minimal, patternF755Apr 10, 2026

  Based on observation, interview, and record review, for three of 18 sampled residents (Residents 37, 3 and 6), the facility failed to ensure pharmaceutical services were provided when ordered medications were not available for administration.1. For Resident 37, the physician-ordered as-needed pain medication was not available for administration. This resulted in Resident 37's inadequate pain management.2. Resident 3's physician-ordered Namenda tablet 10 mg (Memantine HCl - indicated for the treatment of moderate to severe dementia of the Alzheimer's type) was not available for administration. This failure had the potential to result in decreased therapeutic benefit and decline in overall functioning.3. […]

• No harm, potential for more than minimal, patternF759Apr 10, 2026

  Based on observations, interviews, and record review, the facility failed to ensure that medication error rate was below 5%. There were four errors out of 31 medication pass observations which resulted in 12.9% error rate. 1. Resident 6's Resident 6's physician-ordered Ipratropium-Albuterol Solution (medication used to help control the symptoms of lung diseases) was not available for administration. Resident 6's Minoxidil (medication used to treat high blood pressure) oral tablet was not administered. Resident 6's Hydralazine (medication used to treat high blood pressure) oral tablet was not administered. These failures had the potential to affect Resident 6's health and safety due to worsening of respiratory illness and high blood pressure.2. […]