Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

There are  181 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey in response to one complaint at St. Francis Center For Rehabilitation & Healthcare, completed on March 23, 2023, it was determined that facility was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

 Plan of Correction:

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Based on observations, resident interview, it was determined that facility failed to provide personal and grooming care for a dependent resident for one out of seven residents reviewed. (Resident R4)

Findings include:

Review of Resident R4's clinical record revealed the diagnoses of acute and chronic respiratory failure with hypoxia (below-normal level of oxygen in the blood), chronic obstructive pulmonary disease (disease process that causes decreased ability of the lungs to perform), morbid obesity, cerebral infarction (stroke), muscle weakness and partial traumatic amputation of left foot.

Review of Resident R4's significant change Minimum Data Set (MDS assessment of resident care needs) dated February 11, 2023, revealed that the resident required extensive assistance of two staff members with bed mobility, transfers, dressing and personal hygiene.

Observations on March 23, 2023 at 11:27 a.m. revealed Resident R4 was lying in bed and calling out for assistance. Nursing staff was observed walking past Resident R4's room while resident was calling out at 11:30 a.m.

Another nursing staff member walked past Resident R4's room at 11:35 a.m. without acknowledging resident while she was calling out "help me, help me, I need help in here."

Review of Unit 2 Main 'CNA (nurse aide) Assignment 7-3" for March 23, 2023 states: "Staff: All residents are to be up by 11 a.m. Please clean residents hands before and after meals."

Interview with Resident R4 revealed resident was concerned regarding not receiving assistance for mass services which were held "daily at 10:30 a.m." Resident stated, "I would like to get out of bed and be changed."

Additional observations on March 23, 2023, 12:00 p.m. revealed that it was not until 12:00 p.m. that Assistant of Director of Nursing, was observed providing incontinence care to the resident.

28 Pa. Code 211.10(a)(d) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing services

 Plan of Correction - To be completed: 04/18/2023

1. Resident R4 was provided incontinence care.
2. All residents were evaluated if they required grooming care. If a resident requires groom care they were provided with the care.
3. Nursing staff were educated on the importance of assisting residents when they request care.
4. Director of Nursing or designee will audit care being provided to residents to ensure care was provided as requested. Results of the audit will be completed once a week for four weeks. The results of the audit will be reviewed at the monthly QAPI meeting.

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