St. Francis Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Apr 24, 2025

  Based on observation, interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure appropriate and timely care when Resident #1 had a fall on 4/16/2025 and was diagnosis with a fractured C1 vertebrae, traumatic subarachnoid hemorrhage, scalp laceration requiring repair and hematoma/contusion. 2. The facility failed to ensure LVN B did not move Resident #1 with a mechanical lift after a fall on 04/16/2025. 3. […]

• Immediate jeopardy, isolatedF689Apr 24, 2025

  Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1), reviewed for quality of care. The facility failed to supervise Resident #1 when she was left unattended during care while CNA A retrieved supplies and resulted in a fall with a head injury, scalp laceration, hematoma/contusion to the forehead/scalp, traumatic subarachnoid hemorrhage and fracture to the C-1 vertebrae of her neck. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/23/25. The noncompliance began on 4/16/2025 and ended on 4/22/2025. […]

• No harm, potential for more than minimal, patternF921Jan 23, 2026

  Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 resident hall (Hall 200) of 4 resident halls reviewed, in that:Potentially harmful cleaning materials were unsecured in resident Hall 200.This deficient practice could result in an unsafe environment for residents, staff, and the public.The findings were:Observation on 01/20/2026 at 12:18 p.m. revealed a can of disinfectant spray on top of a cart located at the far end of Hall 200. Further observation revealed the disinfectant was labeled, Caution, keep out of reach of children. […]

• No harm, potential for more than minimal, patternF812Oct 18, 2024

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to store, label and date food items properly in the walk-in cooler, freezer, and dry storage room. 2. The facility failed to store a dented can in a separate location in the dry storage room. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. a. Observation on 10/15/2024 at 8:40 AM in the walk-in cooler revealed a half-gallon container of Lactose-Free whole milk. The container had been opened with approximately 1/2 of the milk remaining in the container. […]

• No harm, potential for more than minimal, patternF813Oct 18, 2024

  Based on observation, interview, and record review, the facility failed to have a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption of residents' food items for 4 of 5 resident refrigerators (refrigerators in resident Rooms 115, 208, 213, and 215) reviewed for personal food policy, in that: 1. The personal refrigerators in three residents' Rooms (115, 208, and 215) contained food items which were unlabeled and undated. 2. The internal temperature of the refrigerator on resident room [ROOM NUMBER] exceeded 41 degrees Fahrenheit. These deficient practices could place residents at risk of foodborne illness due to consuming foods which were spoiled. The findings were: 1. a. […]