St Francis Home

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF755Sep 11, 2024

  Based on observation, interview and document review, the facility failed to ensure medications were administered according to the standard of practice for 8 of 13 residents (R1, R2, R4, R5, R7, R8, R9, R10) reviewed for medication administration. Findings include: R1's physician order summary dated 7/18/24, identified the following medications were ordered: Tylenol 325 milligrams (mg) by mouth give two tablets (650 mg) three times a day. Sucralfate give one gram by mouth two times a day. R2's physician order summary dated 8/15/24, identified the following medications were ordered: Calcium-Vitamin D 600-400 mg-unit by mouth daily. CertaVite Senior multivitamin by mouth daily. Cranberry 500 mg by mouth daily. Dalfampridine Extended Release 12 hour give 10 mg by mouth twice a day. […]

• No harm, potential for more than minimal, patternF700Jul 17, 2024

  Based on observation, interview, and document review, the facility failed to comprehensively assess, discuss risks and benefits, obtain informed consent and attempt alternatives prior to use of bed rails for 9 of 12 residents (R11, R14, R3, R19, R6, R7, R16, R22, R188 ) reviewed who were observed to have bed rails raised while in bed. Findings include: R11 R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had severe cognitive impairment with diagnoses which included diabetes mellitus, anxiety and depression. R11's MDS identified R11 required supervision and touching assistance to roll left and right and substantial/maximal assistance for bed to chair transfer. […]

• No harm, potential for more than minimal, patternF812Jul 17, 2024

  Based on observation, interview and document review, food and drinks were not served in a sanitary and clean manner for residents observed during dining observations in both dining rooms. This deficient practice had the potential to affect all residents who ate their meals in the dining rooms. Findings include: During an observation on 7/15/24 at 11:47 a.m., cook (C)-A began to set up the steam table in the A wing dining room. At 11:53 a.m., C-A began serving the lunch meal which included sloppy joes on a bun with gloves on. Each resident had a dietary card in a plastic sleeve in a binder. C-A would flip the pages with her right hand, then remove a bun with her left hand, open the buns with both gloved hands, then place them on the plates. […]

• No harm, potential for more than minimal, patternF880Aug 8, 2023

  Based on observation, interview, and document review, the facility failed to ensure personal laundry was transported in a manner that prevented risk of contamination for 2 of 4 hallways observed for linen transportation. In addition, the facility failed to ensure proper hand hygiene and glove use was implemented during food preparation in 1 of 2 kitchenettes observed for food prep. Findings include: Review of Centers for Disease Control (CDC )guidance , Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. […]

• No harm, potential for more than minimal, isolatedF677Jun 9, 2026

  Based on observation, interview and document review, the facility failed to provide assistance with routine grooming cares which included oral cares for 1 of 2 residents (R34) reviewed for activities of daily living (ADLs) who required assistance with grooming and personal hygiene.Findings Include: R34's quarterly Minimum Data Set (MD) dated 4/28/26, identified R34 had severe cognitive impairment with diagnoses which included: Alzheimer's disease, anxiety and depression. R34's MDS identified R34 was dependent on staff for eating, oral hygiene, personal hygiene, and dressing. R34's care plan revised 5/13/26, identified R34 had self-care performance deficit related to Alzheimer's disease and dementia along with Impaired balance and weakness. […]