St Francis Senior Ministries

In the surveyor’s words

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

• Immediate jeopardy, isolatedF742May 4, 2022

  Based on observation, medical record review, interviews with staff and family, review of a hospice self-reported incident, and review of facility policies, the facility failed to accurately assess and develop a care plan addressing the mental health status, including hallucinations and delusions, fall risk, and level of supervision for Resident #01. This resulted in Immediate Jeopardy on 04/15/22 at approximately 11:50 P.M. when Resident #01 either jumped or fell from a second-floor window and was found on the ground on a concrete patio. Serious harm of bodily injuries occurred when Resident #01 sustained a fractured left ankle, fractured left tibia, and internal swelling. […]

• No harm, potential for more than minimal, widespreadF921Apr 10, 2025

  Based observation and staff interview the facility failed to ensure the facility was adequately maintained. This had the potential to affect all 52 residents residing in the facility. The facility census was 52. Findings include: Observation on 04/10/25 from 8:09 A.M. through 9:05 A.M., during an environmental tour with the Administrator, revealed the following: Outside the main elevator on the first floor, and continued down the hallway and into the dining room, were damaged and improperly fitted ceiling tiles. […]

• No harm, potential for more than minimal, widespreadF727Mar 16, 2023

  Based on staff interview and review of facility documentation, the facility failed to ensure facility daily staffing included a Registered Nurse (RN) for eight hours during a 24-hour period. This had the potential to affect all 79 residents residing in the facility. Findings include: Review of the facility's staffing schedules between 03/06/23 and 03/12/23 revealed the facility did not have a RN for eight hours in the 24-hour period on Sunday 03/12/23. Interview on 03/13/23 at 2:56 P.M. with the Administrator revealed the facility's staffing schedules were reviewed and the Administrator confirmed the facility lacked RN coverage for the entire day on 03/12/23 during a 24-hour period. This deficiency represents non-compliance investigated under Complaint Number OH00140552.

• No harm, potential for more than minimal, patternF761Mar 16, 2023

  Based on observation, staff interview, and review of the facility policy, the facility failed to ensure resident medications were kept secured and out of reach of cognitively impaired and independently mobile residents. This affected one resident (#327) and had the potential to affect four additional residents who were cognitively impaired and independently mobile (#29, #49, #68, and #177) on the two-east hall. The facility census was 79. Findings Include: Observation on 03/15/23 at 4:07 P.M. revealed a medication cart located on two east was unlocked and unattended with loose pills in a clear plastic medication cup on top of the medication cart. […]

• No harm, potential for more than minimal, patternF803Mar 16, 2023

  Based on resident and staff interview, record review, observation of meal service, review of the facility menu, recipe review, and review of facility policy, the facility failed to ensure residents who received pureed meals from the second floor kitchen received the correct serving sizes. This affected five (#20, #24, #33, #36, and #177) of five residents who received pureed meals on the second floor. In addition, the facility failed to follow the approved menu and recipe during meal service. This affected all residents except 14 (#5, #12, #15, #20, #24, #33, #36, #59, #60, #64, #68, #177, #179, and #180) identified by the facility as not having the food items for which the recipe was not followed. The facility census was 79. Findings include: 1. […]