Inspection Reports for
St Francis Manor
2021 Fourth Avenue, Grinnell, IA, 501122064
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
77% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
54 residents
Based on a July 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 17, 2025
Visit Reason
Annual survey inspection of St Francis Manor nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 17, 2025
Visit Reason
An Annual Recertification Survey was conducted from April 14, 2025 to April 17, 2025.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
Annual survey inspection of St Francis Manor nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
The inspection was conducted as an annual recertification survey and included an investigation of a facility reported incident #121097-I.
Complaint Details
Facility reported incident #121097-I was investigated and found not substantiated.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. The reported incident #121097-I was not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
An investigation of Complaints #114900-C, #117622-C, #117624-C and Facility Self-Reported Incidents #114899-I and #114963-I was conducted from January 25, 2024 to January 31, 2024.
Complaint Details
Investigation involved multiple complaints and self-reported incidents; facility found in substantial compliance.
Findings
The facility was found in substantial compliance at the time of the investigations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 2, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction for the facility, indicating acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction, with certification effective August 13, 2023.
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Jul 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement care plan interventions based on a root cause analysis of a resident's specific fall risks to prevent a fall with major injury.
Complaint Details
The complaint investigation found that the facility did not adequately address fall prevention for Resident #103, who fell and sustained a right femoral neck fracture. The resident was at risk due to intermittent confusion, poor vision, and balance problems. Staff interviews revealed gaps in supervision and communication about the resident's mobility and call light use. The deficiency was substantiated with minimal harm to residents.
Findings
The facility failed to implement appropriate fall prevention interventions for Resident #103, who sustained a right femoral neck fracture after a fall. The care plan lacked adequate interventions despite the resident's known fall risks, and staff observations indicated insufficient supervision and communication regarding the resident's mobility and use of call light.
Deficiencies (1)
Failure to implement care plan interventions based on a root cause analysis of a resident's specific fall risks to prevent a fall with major injury.
Report Facts
Residents affected: 3
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse (RN) | Observed resident after fall and educated resident to use call light |
| Staff E | Certified Medication Aide (CMA) | Discovered resident on floor and informed nurse |
| Staff F | Certified Nursing Assistant (CNA) | Observed resident walking alone and redirected her |
| Staff D | Licensed Practical Nurse (LPN) | Worked night shift when resident arrived and noted resident's confusion |
| Staff G | Care Plan Coordinator | Described fall assessment and intervention process |
| Director of Nursing (DON) | Director of Nursing | Commented on resident's assist level and fall circumstances |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Jul 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement care plan interventions to prevent falls, specifically for one resident who experienced a fall with major injury.
Complaint Details
The complaint investigation found that the facility did not adequately address fall prevention for Resident #103, who had intermittent confusion, poor vision, balance problems, and a history of falls. The resident fell and sustained a right femoral neck fracture requiring surgery. Staff interviews revealed inconsistent supervision and lack of timely interventions.
Findings
The facility failed to implement fall prevention interventions based on a root cause analysis for one of three residents reviewed for falls. The resident fell resulting in a right femoral neck fracture requiring surgical repair. The care plan lacked adequate interventions to address the resident's fall risks despite documented history and risk factors.
Deficiencies (1)
Failure to implement care plan interventions based on root cause analysis to prevent falls for a resident at risk.
Report Facts
Residents affected: 1
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse (RN) | Observed resident after fall and provided education on call light use |
| Staff E | Certified Medication Aide (CMA) | Discovered resident on floor and informed nurse |
| Staff F | Certified Nursing Assistant (CNA) | Observed resident walking alone and redirected her |
| Staff D | Licensed Practical Nurse (LPN) | Worked night shift when resident was found up and about |
| Staff G | Care Plan Coordinator | Described fall assessment and intervention process |
| Director of Nursing (DON) | Director of Nursing | Commented on resident's assist level and fall circumstances |
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 1
Date: Jul 13, 2023
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of a Facility Self-Reported Incident #113329-I from July 10 to July 13, 2023.
Complaint Details
Facility Self-Reported Incident #113329-I was substantiated.
Findings
The facility failed to implement care plan interventions to prevent falls for a resident at risk, resulting in a substantiated incident involving a fall with major injury. The facility did not adequately monitor and intervene to prevent falls, violating federal regulations.
Deficiencies (1)
Failure to implement care plan interventions based on root cause analysis to prevent falls for a resident at risk, resulting in a fall with major injury.
Report Facts
Resident census: 54
Incident dates: Incident investigation period from July 10, 2023 to July 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Vander Molen | Human Resources Specialist | Signed the statement of deficiencies and plan of correction |
| Staff C | Registered Nurse (RN) | Observed resident after fall and reported findings |
| Staff E | Certified Medication Aide (CMA) | Discovered resident on floor after fall |
| Staff F | Certified Medication Aide (CMA) | Discovered resident on floor after fall |
| Staff D | Licensed Practical Nurse (LPN) | Reported on resident behavior prior to fall |
| Staff G | Care Plan Coordinator | Discussed fall assessment and interventions |
| Director of Nursing (DON) | Evaluated resident and commented on fall circumstances |
Inspection Report
Deficiencies: 0
Date: Apr 13, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for St Francis Manor, documenting the results of a regulatory survey completed on April 13, 2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Date: Apr 11, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaint #102077-C and a Facility Self-Reported Incident #109389-I were conducted by the Department of Inspections and Appeals from April 11, 2023 to April 13, 2023.
Complaint Details
Investigation of Complaint #102077-C and Facility Self-Reported Incident #109389-I was conducted; facility found in substantial compliance.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 and was also found to be in overall substantial compliance.
Report Facts
Total Residents: 58
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 2
Date: Oct 28, 2021
Visit Reason
The inspection was conducted as the facility's annual health survey to assess compliance with federal and state regulations.
Complaint Details
Complaint #95259-C was investigated and found not substantiated.
Findings
The facility was found deficient in providing a bed hold notice upon hospital transfer for 1 of 2 residents reviewed, and failed to implement interventions to prevent pressure ulcers for 1 of 3 residents reviewed. The complaint #95259-C was not substantiated.
Deficiencies (2)
Failure to provide a bed hold notice upon hospital transfer for 1 of 2 residents.
Failure to implement interventions to prevent pressure ulcers for 1 of 3 residents reviewed.
Report Facts
Census: 40
Complaint number: 95259
Incident number: 96910
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding bed hold policy and pressure ulcer prevention. |
| Administrator | Administrator | Interviewed regarding bed hold policy and facility practices. |
| Staff A | Registered Nurse | Observed providing care related to pressure ulcer prevention. |
| Staff B | Interviewed regarding discovery of pressure ulcer. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 27, 2020
Visit Reason
The inspection was conducted as a recertification and annual survey of the facility to assess compliance with federal regulations.
Findings
The facility was found to be in substantial compliance at the time of the recertification and survey conducted from August 24 to 27, 2020.
Inspection Report
Routine
Census: 42
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Viewing
Loading inspection reports...
