Mount St Francis Nursing Center

• Staffing

  Total nurse staffing reported to CMS went from 3.9 to 3.5 hours per resident per day.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Health citation

  CMS changed citation F0600 from severity E to D. It is from the health inspection on August 17, 2023. Severity D: potential for more than minimal harm, isolated.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Health citation

  CMS changed citation F0600 from severity D to E. It is from the health inspection on August 17, 2023. Severity E: potential for more than minimal harm, pattern.

• Fire safety citation

  CMS removed citation K0211 from the fire safety inspection on March 25, 2025.

• Fire safety citation

  CMS removed citation K0293 from the fire safety inspection on March 25, 2025.

• Fire safety citation

  CMS removed citation K0321 from the fire safety inspection on March 25, 2025.

• Fire safety citation

  CMS removed citation K0324 from the fire safety inspection on March 25, 2025.

• Fire safety citation

  CMS removed citation K0345 from the fire safety inspection on March 25, 2025.

• Fire safety citation

  CMS removed citation K0353 from the fire safety inspection on March 25, 2025.

• Fire safety citation

  CMS removed citation K0363 from the fire safety inspection on March 25, 2025.

• Fire safety citation

  CMS removed citation K0372 from the fire safety inspection on March 25, 2025.

• Fire safety citation

  CMS removed citation K0914 from the fire safety inspection on March 25, 2025.

• Fire safety citation

  CMS removed citation K0918 from the fire safety inspection on March 25, 2025.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

• CMS abuse icon

  CMS added its abuse icon to this home.

• Health citation

  CMS removed citation F0622 from the health inspection on March 6, 2025.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0730. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Observe each nurse aide's job performance and give regular training.

  CMS lists it as corrected on April 5, 2025.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on April 5, 2025.

  CMS has cited this home for F0600 2 times since 2023.

• Citation F0622. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on April 5, 2025.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on April 5, 2025.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on April 5, 2025.

  CMS has cited this home for F0880 3 times since 2023.

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CMS lists this as a standard inspection.

• Citation E0001. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish an Emergency Preparedness Program (EP).

  CMS lists it as corrected on April 5, 2025.

• Citation E0015. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Address subsistence needs for staff and patients.

  CMS lists it as corrected on April 5, 2025.

• Citation E0036. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish emergency prep training and testing.

  CMS lists it as corrected on April 5, 2025.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on April 5, 2025.

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• Star rating

  The CMS overall star rating changed from 4 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• Changed ownership in the last 12 months

  CMS no longer shows a change of ownership in the past 12 months.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• Name

  CMS lists a new legal business name for this home.

• Ownership

  CMS lists this home under a new chain.

• Changed ownership in the last 12 months

  CMS records show a change of ownership in the past 12 months.

• Name

  CMS lists a new legal business name for this home.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Health citation

  CMS changed citation F0600 from severity E to D. It is from the health inspection on August 17, 2023. Severity D: potential for more than minimal harm, isolated.

CMS lists this as a complaint inspection.

• Citation F0882. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

  CMS lists it as corrected on January 17, 2024.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on January 5, 2024.

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CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on September 16, 2023.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on September 16, 2023.

• Citation F0806. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on October 30, 2023.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on September 16, 2023.

• Citation F0563. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

  CMS lists it as corrected on November 15, 2023.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on September 28, 2023.

• Citation F0676. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on September 16, 2023.

  CMS has cited this home for F0676 2 times since 2019.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on September 16, 2023.

• Citation F0726. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on September 16, 2023.

• Citation F0744. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

  CMS lists it as corrected on September 16, 2023.

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CMS lists this as a standard inspection.

• Citation F0676. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on September 18, 2019.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on September 18, 2019.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on September 18, 2019.

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