Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Francis Health Services during CMS and state inspections, most recent first.
A resident reported that a visitor yelled at and shook her, and may have previously taken money. While the incident was reported to the police and staff were instructed to prevent the visitor from returning, the facility did not interview staff or other residents as part of the investigation, contrary to policy requirements.
The facility did not accurately calculate or analyze infection rates, as the DON included ongoing and chronic infections in monthly counts and did not separate facility-associated from community-based infections. Infection surveillance reports lacked calculations for individual infection types, and no policy or standard practice for infection rate calculation was provided.
A resident with severe cognitive impairment and a history of falls experienced three unwitnessed falls that were not thoroughly investigated to determine root causes. Documentation was incomplete, lacking details on toileting and incontinence status, and interventions such as increased toileting assistance were delayed. The facility's response did not align with its own policies for hazard identification and timely intervention.
A resident with dysphagia and a physician-ordered pureed diet was served a banana that was only cut in half and left in the peel, rather than being pureed as required. The facility's dietary guidelines and the resident's care plan specified that all foods, including bananas, must be pureed to ensure safe consumption. Staff confirmed the error after it was observed by a surveyor, and the uneaten banana was found on the resident's bedside table.
A resident on a mechanically-altered diet was served pureed foods at temperatures below the required 135°F, and kitchen staff failed to follow proper hand hygiene protocols by not washing hands between glove changes or after handling kitchen equipment, contrary to facility policy.
Failure to Conduct Thorough Investigation of Alleged Visitor Abuse
Penalty
Summary
The facility failed to ensure a thorough and properly documented investigation regarding an alleged visitor-to-resident altercation involving one resident. According to the facility's policy, investigations of alleged abuse must include identifying and interviewing all involved persons, including the alleged victim, perpetrator, witnesses, and others who might have knowledge of the allegation. In this case, the resident reported that a friend and former caregiver visited her, yelled at her, shook her by the arms, and may have previously taken money from her. The incident was reported to the social worker by a CNA, and the police were contacted to take the resident's statement. The facility also posted a notification to staff to prevent the friend from visiting the resident. However, the investigation did not include interviews with facility staff who may have had relevant information about the incident, nor were any other residents interviewed. The administrator stated that staff were not interviewed because the incident did not involve facility staff, and the social services director confirmed that no other residents were interviewed as there were no witnesses. The resident was assessed and found to have no physical marks and continued to participate in meals, therapy, and activities without ill effects. The lack of comprehensive staff interviews and documentation of the investigation process constituted a failure to follow the facility's abuse investigation policy.
Failure to Accurately Calculate and Analyze Infection Rates
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by inaccurate calculation and analysis of infection rates. The Director of Nursing (DON), who oversees the infection control program, reported that individual rates of infection were not calculated, and infections were counted in multiple months if they persisted or were chronic. Additionally, the DON did not distinguish between facility-associated and community-based infections when compiling infection data. Monthly infection surveillance reports reviewed from October 2024 to March 2025 only included the number of infections, without calculations for each type of infection, and combined both community and facility-associated infections in the total rates. Further review of the facility's infection surveillance logs revealed that infections from previous months and chronic infections, such as those due to multiple drug-resistant organisms, were included in the infection rates. When asked, the DON was unable to provide a facility policy or standard practice for calculating infection rates. The surveyor notified the Nursing Home Administrator and the DON of these findings, and no additional information or justification was provided for the lack of proper infection rate calculations or the failure to use only new, healthcare-associated infections in the infection rate data.
Failure to Investigate and Address Causes of Multiple Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision and thorough investigation of falls for a resident with a history of multiple unwitnessed falls. The resident, who had severe cognitive impairment, incontinence, and multiple diagnoses including dementia and psychosis, experienced three unwitnessed falls. Each fall was not thoroughly investigated to determine the root cause, and interventions were not promptly or appropriately updated to address the underlying issues. For example, after a fall related to toileting needs, the care plan was not revised to increase toileting assistance until two months later. Documentation and post-fall assessments lacked critical information, such as the resident's incontinence status at the time of each fall, the timing of the last toileting, and whether the resident had the capacity to use a call light for assistance. In one instance, the intervention implemented was to provide a different type of call light, despite staff interviews indicating the resident did not use the call light intentionally. Additionally, there was confusion and lack of clarity in documentation regarding the use of assistive devices, such as whether a walker or wheelchair was in use at the time of a fall. Interdisciplinary team meetings were held after each fall, but the interventions developed were not always based on a thorough root cause analysis. The facility's own policy required systematic identification, evaluation, and analysis of hazards and risks, as well as timely implementation and communication of interventions. However, the investigation and documentation following each fall did not consistently meet these standards, resulting in missed opportunities to prevent further incidents.
Failure to Provide Pureed Food as Ordered for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered Level 1/pureed diet due to dysphagia was served a banana that was only cut in half and left in the peel, rather than being pureed as required by the resident's diet order and meal ticket. The facility's own Diet/Texture Conversion Chart and national guidelines specify that foods on a pureed diet must be homogenous, cohesive, and pudding-like, with fresh bananas to be served well-mashed or pureed. During meal preparation, the surveyor observed that while other items on the resident's tray were properly pureed, the banana was not, and this was confirmed by both the Food Service Manager and a CNA, who acknowledged the error. The resident's care plan and physician orders documented the need for a pureed diet with honey-thickened liquids due to swallowing difficulties, edentulism, and nutritional risk. Despite these documented needs, the resident was served a banana in a form inconsistent with the prescribed diet. The surveyor observed the uneaten banana on the resident's bedside table after the meal, indicating it was not consumed. The deficiency was discussed with facility leadership during the survey process.
Failure to Maintain Food Safety and Hand Hygiene During Meal Preparation
Penalty
Summary
Food was not prepared and served in a sanitary manner for a resident on a mechanically-altered diet. Specifically, pureed foods prepared for the resident were served at temperatures below the required 135 degrees Fahrenheit, with recorded temperatures of 102, 106, and 108 degrees for various food items. The facility's policy requires hot pureed foods to be reheated to at least 165 degrees for 15 seconds if they fall below 135 degrees, but this was not done before the food was served to the resident. Additionally, improper glove use and hand hygiene practices were observed in the kitchen. The cook was seen changing gloves multiple times without washing hands between glove changes, and at one point, reused a glove after opening a drawer without handwashing or using a new glove. The facility's policy and training materials clearly state that hands must be washed before putting on gloves and between glove changes, but these procedures were not followed during food preparation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 579 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Francis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wheaton Franciscan Hc - Terrace At St Francis | 2.9 mi | — | 12 | 0 |
| St Ann Health And Rehabilitation Center | 3.7 mi | — | 11 | 0 |
| Autumn Lake Healthcare At Greenfield | 4.1 mi | — | 5 | 1 |
| Mercy Health Services | 4.1 mi | — | 3 | 0 |
| Maple Ridge Health Services | 4.2 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St Francis Health Services.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.