Mount St Francis Nursing Center

Emergency Preparedness Deficiencies

Establish an Emergency Preparedness Program (EP).

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.Difienceint items were confirmed with the maintenance team during the survey1.Fire Alarm Panel showing ground fault troubleNFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complyi.. Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:Difienceint items were confirmed with the maintenance team during the survey1. Polarity retention report lists multiple receptacles as failed retention testing NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Ca.. Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: Difienceint items were confirmed with the maintenance team during the survey1. Fuel report for generator shows fuel failed8.1.1 The routine Maintenance and operational testing program shal.. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain hazard areas in accordance with NFPA 101.Difienceint items were confirmed with the maintenance team during the survey1.Self closures need to repaired on doors for both transfer rooms garden level2. Storage needs to be removed from concealed space on garden level8.7.1.1* Protection from any area having a degree of hazard gr.. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. Difienceint items were confirmed with the maintenance team during the survey1. Penetrations were found in 3rd-floor lounge firewall (3-hour), above corridor fire doors 3 floor and 2nd-floor dining room, and above the corridor barrier. Barriers should be repaired to maintain their listed r.. Based on observation, it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. Difienceint items were confirmed with the maintenance team during the survey1. Commercial stove needs an approved device to return to its original position after cleaning2. Information on tag inspection suppression missing fusible links temperature and date changedNFPA 96, 12.1.2.3 The fire-extinguishing system shall .. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101Difienceint items were confirmed with the maintenance team during the survey1. Sprinkler Gauges Outdated2. Anti-freeze in open house written a deficiency on annual sprinkler report3. FDC needs to identify to which facility they serve4. No general infor.. This survey was conducted in accordance with the Federal Register at Section 42 CFR § 483.90The initial comments (ID Prefix Tag K-000) are informational only and are a representation of the facility' s general characteristics.This facility is a three-story, Type II (111) structure with a garden level basement and a penthouse. The residents use the basement for the beauty shop and the massage room. The basement and the penthouse contain offices and su.. Through observation during the survey, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101, 19.2.10.1Difienceint items were confirmed with the maintenance team during the survey1. Emergency lighting 30sec monthly inspection not available for review2. Exit lighting 30sec monthly inspection not available for review3. Exit lighting 90min annual inspection not available for review4 .Exit lighting ove..

A recertification survey with complaint #CO38668, #CO38670, #CO38703, #CO39273 and Incident #39413 was completed on 3/3/25 to 3/6/25. Five deficiencies were cited. An Emergency Preparedness survey was conducted from 3/3/25 to 3/6/25. Four deficiencies were cited. Based on interviews and record review, the facility failed to initiate an appropriate facility-initiated discharge for one (#58) of three residents reviewed for appropriate discharge out of 32 sample residents. Specifically, the facility failed to:-Complete an assessment with attempted interventions prior to giving the resident a discharge notice; and,-Ensur.. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment for residents to help prevent the development and transmission of diseases and infection on one of three units. Specifically, the facility failed to:-Ensure staff wore the appropriate per.. Based on observations, record review and interview, the facility failed to develop and implement emergency preparedness policies and procedures based on the emergency plan that identified the provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: food, .. Based on observations, record review and interviews, the facility failed to ensure proper storage of medications in one of three medication storage rooms and three of three medication storage carts.Specifically, the facility failed to:-Ensure medications were labeled with the date they were opened; and,-Ensure expired or discontinued medicatio.. Based on record review and interview, the facility failed to develop and maintain an up-to-date emergency preparedness training and testing program that was based on the facility' s emergency preparedness (EP) program plan, annual risk assessment, facility EP policies and procedures and the communication plan that was delivered to all staf.. Based on record review and interview, the facility failed to establish and maintain a comprehensive emergency preparedness (EP) program that met all of the standards specified within the condition/requirement. To include a comprehensive approach to meeting the health, safety, and security needs of their staff and patient population durin.. Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for three of three certified nurse aides (CNA).Specifically, the facility to complete regular in-service education based on the o.. Based on record review and interviews, the facility failed to conduct two exercises annually to test the facility' s emergency plan and maintain documentation of the facility' s response to all drills, tabletop exercises, and emergency events, and then revise the facility' s emergency plan, as needed.Specifically, the facility failed to:-Participate in a c.. Based on record review and interviews, the facility failed to ensure one (#16) of two residents reviewed for abuse out of 46 sample residents was free from abuse. Specially, the facility failed to protect Resident #16 from sexual abuse by Resident #58.Findings include:I. Incident of sexual abuse between Resident #16 and Resident #58 on 11/14/..