St Francis Manor

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF607Feb 11, 2026

  Based on staff certification review, policy review, and staff interviews, the facility failed to ensure 1 of 6 staff members reviewed for Dependent Adult Abuse(DAA) Mandatory Reporter's Training had current training(Staff A). The facility reported a census of 59 residents.Findings included:The facility Abuse Prevention, Identification, Investigation, and Reporting Policy, revised 12/16/22, stated each employee would complete 1-hour reporting of dependent adult abuse training every three years.An undated facility document entitled Hire Date, documented Staff A Maintenance Staff's hire date as 4/21/08.A DAA Mandatory Reporter Training Course certificate, dated 12/31/25, stated Staff A successfully completed the course.On 2/11/26 at 12:15 p.m., via phone, Staff A stated he had trouble passing… […]

• No harm, potential for more than minimal, isolatedF689Jul 13, 2023

  Based on clinical record review, facility policy review, observations and staff interviews, the facility failed to implement Care Plan interventions based on a root cause analysis of a resident's specific fall risks in order to prevent a fall with a major injury for 1 of 3 residents reviewed for falls(Resident #103). The facility reported a census of 54 residents. Findings: The Entry Minimum Data Set (MDS) Assessment Tool, dated 5/31/23, stated the resident admitted to the facility on [DATE]. The 1/19/17 facility policy Resident Falls, directed staff regarding the procedure following a fall. The policy did not address the implementation of interventions to prevent falls for residents who had not fallen but had risks. […]

• No harm, potential for more than minimal, isolatedF686Oct 28, 2021

  Based on clinical record review, observation, facility policy review, and staff interview, the facility failed to implement interventions to prevent a facility acquired pressure ulcer for 1 of 3 residents reviewed.(Resident #32). The facility reported a census of 40 residents. Findings: The MDS (Minimum Data St) assessment defines pressure ulcers as follows: Stage I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II - A partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. The wound may also present as an intact or open/ruptured blister. […]

• No harm, potential for minimal, patternF625Oct 28, 2021

  Based on clinical record review, policy review, and staff interview, the facility failed to provide a bed hold notice upon hospital transfer for 1 of 2 residents who transferred to the hospital (Resident #8). The facility reported a census of 40 residents. Findings: 1. The MDS (Minimum Data Set) assessment, dated 8/19/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS listed the resident's BIMS (Brief Interview for Mental Status) score as 9 out of 15, indicating moderately impaired memory and cognition. Nursing Notes dated 8/5/21 recorded Resident #8 transferred to the hospital for shortness of breath. Nursing Notes dated 8/10/21 documented Resident #8 returned to the facility. […]