Inspection Reports for
St Francis Manor

Investigation of intakes #2745972-C and #3003750-I.

No regulatory insufficiencies were cited.

Based on acceptance of the credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance with health requirements effective March 4, 2026.

Complaint #2712870-C

The facility failed to ensure that 1 of 6 staff members reviewed had current Dependent Adult Abuse Mandatory Reporter Training. Staff A struggled with the test and did not complete it properly, and the facility was unaware of this until the investigation.

No health deficiencies were found during the inspection.

Facility reported incident #121097-I was investigated and found not substantiated.

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.

Investigation involved multiple complaints and self-reported incidents; facility found in substantial compliance.

The facility was found in substantial compliance at the time of the investigations.

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.

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.

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.

Facility Self-Reported Incident #113329-I was substantiated.

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.

No health deficiencies were found during the inspection.

Investigation of Complaint #102077-C and Facility Self-Reported Incident #109389-I was conducted; facility found in substantial compliance.

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.

Complaint #95259-C was investigated and found not substantiated.

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.

The facility was found to be in substantial compliance at the time of the recertification and survey conducted from August 24 to 27, 2020.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.