St Francis Medical Center

“NUMBER OF BEDS AND LENGTH OF STAY CFR(s): §485.620 Condition of Participation: Number of Beds and Length of Stay This Condition is not met as evidenced by: 38687 Based on documentation and interview, the facility failed to ensure acute inpatient care periods did not exceed 96 hours per patient on an annual average basis. Findings include: Review of the facilities Hospital and Hospital Health Care Complex Cost Report Certification and Settlement Summary Report used in lieu of Form CMS-2552-10 for the time-period of 7/1/23 through 6/30/24 identified on: 1. Page 14 of 113: labeled “Part I- Statistical Data”; in column 4: labeled “CAH/REH Hours”, the facility documented a total of 26,972 hours of stay. 2. Page 16 of 113, labeled “Part 1-Statistical Data”; in column 5: labeled “Total All Patients”, the facility documented a total of 271 patients. The above data averaged identified an average length of stay of 99.90 hours as filed. Interview on 12/11/25 at 9:50 a.m., with the president-chief executive officer (CEO) identified she was aware the facility exceeded the 96-hour average length of stay for the above-mentioned time-period. During that time, the CEO recalled the facility had a mental health patient (who the facility was unable to find placement for) that ended up staying at the facility for approximately 6 months before discharge. The board did review annual reports and were aware they had gone over the 96-hour average length of stay (LOS). The CEO noted the facility did have a length of stay policy and would email the policy to the State Agency (SA). Reply email on 12/11/25, from the CEO identified the facility noted the discrepancy was felt to have been caused by an isolated case. A patient (P1) was admitted to the Acute Care Inpatient department on 5/11/23. P1’s placement with another facility and/or discharge was significantly delayed until 12/5/23, due to factors including homelessness, lack of family support, and mental health issues. The facility’s average length of stay (LOS) was reported as 99.98 hours in the facility’s FY24 Critical Access Hospital (CAH) report, which the CEO felt was significantly impacted by the above-noted single six-month inpatient stay. She noted the total hours reported for the fiscal year FY24 were 26,972. The total included 157 days, equivalent to 3,768 hours, attributed solely to P1. Excluding P1, the annual hours would have been 23,204. When divided by the 271 total patients, the facility noted this would have reduced the average length of stay to be more accurate, at 85.62 average LOS hours. Review of the June 2023 Inpatient Average Length of Stay policy identified average LOS was to be monitored in the following manner: 1. Average LOS was to be calculated on a monthly basis and data was to be reported out. 2. Patient LOS was also monitored by Utilization Review on a daily basis. 3. The facility was to use the daily and monthly monitoring to review existing trends and begin a more intensified review and develop an action plan as necessary to stay within the 96 hour average LOS.”

“LENGTH OF STAY CFR(s): The CAH provides acute inpatient care for a period that does not exceed, on an annual average basis, 96 hours per patient. This Standard is not met as evidenced by: 38687 Based on documentation and interview, the facility failed to ensure acute inpatient care periods did not exceed 96 hours per patient on an annual average basis. Findings include: Review of the facilities Hospital and Hospital Health Care Complex Cost Report Certification and Settlement Summary Report used in lieu of Form CMS-2552-10 for the time-period of 7/1/23 through 6/30/24 identified on: 1. Page 14 of 113: labeled “Part I- Statistical Data”; in column 4: labeled “CAH/REH Hours”, the facility documented a total of 26,972 hours of stay. 2. Page 16 of 113, labeled “Part 1-Statistical Data”; in column 5: labeled “Total All Patients”, the facility documented a total of 271 patients. The above data averaged identified an average length of stay of 99.90 hours as filed. Interview on 12/11/25 at 9:50 a.m., with the president-chief executive officer (CEO) identified she was aware the facility exceeded the 96-hour average length of stay for the above-mentioned time-period. During that time, the CEO recalled the facility had a mental health patient (who the facility was unable to find placement for) that ended up staying at the facility for approximately 6 months before discharge. The board did review annual reports and were aware they had gone over the 96-hour average length of stay (LOS). The CEO noted the facility did have a length of stay policy and would email the policy to the State Agency (SA). Reply email on 12/11/25, from the CEO identified the facility noted the discrepancy was felt to have been caused by an isolated case. A patient (P1) was admitted to the Acute Care Inpatient department on 5/11/23. P1’s placement with another facility and/or discharge was significantly delayed until 12/5/23, due to factors including homelessness, lack of family support, and mental health issues. The facility’s average length of stay (LOS) was reported as 99.98 hours in the facility’s FY24 Critical Access Hospital (CAH) report, which the CEO felt was significantly impacted by the above-noted single six-month inpatient stay. She noted the total hours reported for the fiscal year FY24 were 26,972. The total included 157 days, equivalent to 3,768 hours, attributed solely to P1. Excluding P1, the annual hours would have been 23,204. When divided by the 271 total patients, the facility noted this would have reduced the average length of stay to be more accurate, at 85.62 average LOS hours. Review of the June 2023 Inpatient Average Length of Stay policy identified average LOS was to be monitored in the following manner: 1. Average LOS was to be calculated on a monthly basis and data was to be reported out. 2. Patient LOS was also monitored by Utilization Review on a daily basis. 3. The facility was to use the daily and monthly monitoring to review existing trends and begin a more intensified review and develop an action plan as necessary to stay within the 96 hour average LOS.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 48583 Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital. Findings include: Please refer to the Life Safety Code inspection tags: K0223, K0324, K0353, K0363, K0901 and K0920.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (2) Be ongoing and comprehensive. (3) Involve all departments of the CAH and services (including those services furnished under contract or arrangement). This Standard is not met as evidenced by: 40550 Based on interview and record review the Critical Access Hospital (CAH) failed to ensure Dietary services and Radiology patient care services were evaluated through the quality assurance program. Findings include: Interview and document review on 4/15/24 at 6:30 p.m., with the registered dietitian identified she was aware she was expected to review and develop a Quality Assurance and Performance Improvement (QAPI) project for dietary department however stated she had not had time to do so. Interview and document review on 4/16/24 at 12:45 p.m. with the director of Radiology services identified he had recently started his position and was not aware of the need to review and develop a QAPI plan to be included in the quarterly meetings. Interview on 4/17/24 at 12:15 p.m., with the vice president of clinical services, who identified she was also assisting the new QA coordinator identified her expectation for all departments to participate in development of a QAPI project for their departments. Review of the May 2019 St. Francis Health Quality Assurance/Assessment and Performance Improvement Plan (QAPI) identified the principals drove decision making to promote excellence in all areas of the facility. Departments were to participate in QAPI activities with processes studied and reviewed for 4 months to identify the goal was met and then identify the result of the improvement.”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): Ensure that the CAH works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues, reviewing death records to improve identification of potential donors, and maintaining potential donors while necessary testing and placement of potential donated organs, tissues, and eyes takes place. §485.643(f) For purpose of these standards, the term “organ” means a human kidney, liver, heart, lung, pancreas, or intestines (or multivisceral organs). This Standard is not met as evidenced by: 48583 Based on interview and document review, the critical access hospital (CAH) failed to collaborate and communicate with the Organ Procurement Organization (OPO) to ensure every patient’s death was being reviewed. Findings include: Review of the facility’s Death Report date 3/27/23 to 3/23/24, the facility had 25 deaths. Review of the facility’s Referrals by Hospital Report dated 1/1/23 to 12/31/23, the facility contacted the OPO for 29 facility deaths. On 4/16/24 at 3:04 p.m., vice president of clinical services (VPOCS) and registered nurse (RN)-A confirmed the above findings. RN-A stated she received a quarterly report from the OPO. RN-A stated she reviewed the report and nothing else was done with the report after review. RN-A stated she reviewed the report for the timely compliance rate. RN-A indicated she provided the information to the nurse manager who shared it during a staff meeting. RN-A stated she had not matched the report with reported facility deaths and had not communicated with the OPO regarding the report. RN-A stated the OPO information and report were not part of the quality assurance and performance improvement (QAPI) plan. A policy on OPO was requested however was not provided.”

“DENTAL SERVICES CFR(s): Dental Services (§483.55(a)(2), (3), (4), and (5) and (b) of this chapter). “ §483.55 Dental services. The facility must assist residents in obtaining routine and 24-hour emergency dental care. (a) Skilled nursing facilities. A facility- (2) May charge a Medicare resident an additional amount for routine and emergency dental services; (3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility’s responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility’s responsibility; (4) Must if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services location; and (5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. (b) Nursing facilities. The facility- (1) Must provide or obtain from an outside resource, in accordance with §483.70(g), the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; (2) Must, if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; (3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; (4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility’s responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility’s responsibility; and (5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan. This Standard is not met as evidenced by: 40550 Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure the dental services policy included circumstances identifying the process when the loss or damage of dentures occurred for residents residing in the swing bed (SB) unit. Findings include: Interview on 4/17/24 at 9:45 a.m., case manager registered nurse (RN)-B indicated the facility provided admission information to SB residents when they were admitted related to dental services. RN-B confirmed the CAH’s policies lacked a process when dentures were lost or damaged and who would be responsible for the cost. Interview on 4/17/24 at 1:00 p.m., vice president of clinical services (VPOCS) confirmed after review of policies, the CAH lacked a policy identifying a process for when dentures were loss or damaged. Review of CAH’s policy titled Oral Health Assessment, reviewed 4/22, identified an oral assessment would be completed by the facility within 14 days after admission. The policy lacked a process for when dentures were broken or lost. Review of CAH’s policy titled Patient Care Service Swing Bed in Acute Care revised 4/23, identified the facility would provide routine and 24 hour emergency dental services for swing bed patients. The policy lacked a process for when dentures were broken or lost.”

“FIRE SAFETY An annual Life Safety Code survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 04/16/2024. At the time of this survey, St. Francis Medical Center was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR, Subpart 483.70(a), Life Safety from Fire, and the 2012 edition of National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care and the 2012 edition of NFPA 99, Health Care Facilities Code. THE FACILITY’S POC WILL SERVE AS YOUR ALLEGATION OF COMPLIANCE UPON THE DEPARTMENT’S ACCEPTANCE. YOUR SIGNATURE AT THE BOTTOM OF THE FIRST PAGE OF THE CMS-2567 FORM WILL BE USED AS VERIFICATION OF COMPLIANCE. UPON RECEIPT OF AN ACCEPTABLE POC, AN ONSITE REVISIT OF YOUR FACILITY MAY BE CONDUCTED TO VALIDATE THAT SUBSTANTIAL COMPLIANCE WITH THE REGULATIONS HAS BEEN ATTAINED IN ACCORDANCE WITH YOUR VERIFICATION. PLEASE RETURN THE PLAN OF CORRECTION FOR THE FIRE SAFETY DEFICIENCIES (K-TAGS) TO: IF PARTICIPATING IN THE E-POC PROCESS, A PAPER COPY OF THE PLAN OF CORRECTION IS NOT REQUIRED. Healthcare Fire Inspections State Fire Marshal Division 445 Minnesota St., Suite 145 St. Paul, MN 55101-5145, OR By email to: FM.HC.Inspections@state.mn.us THE PLAN OF CORRECTION FOR EACH DEFICIENCY MUST INCLUDE ALL OF THE FOLLOWING INFORMATION: 1. A detailed description of the corrective action taken or planned to correct the deficiency. 2. Address the measures that will be put in place to ensure the deficiency does not reoccur. 3. Indicate how the facility plans to monitor future performance to ensure solutions are sustained. 4. Identify who is responsible for the corrective actions and monitoring of compliance. 5. The actual or proposed date for completion of the remedy. St Francis Medical Center is part of the St Francis Healthcare Campus. It was built in 2005, is a 1-story building, without a basement and was determined to be Type II (222) construction. It is separated from St Francis Care Center and the Power Plant building with 3- hour fire barriers and is divided into 3 smoke zones with 1-hour fire barriers. The entire building is protected by automatic fire sprinkler systems. The facility has a manual fire alarm system with smoke detectors through the corridor system, in areas open to the corridor and common areas. Hazardous areas have automatic fire detectors that are on the fire alarm system and all sleeping rooms have smoke detectors that alarm outside the rooms and at the nurse’s station that serves that room. This facility was surveyed as one building. The facility has a capacity of 25 beds and had a census of 8 at the time of the survey. The requirement at 42 CFR, Subpart 482.41 (b), is NOT MET as evidenced by:”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 49715 Based on observation and staff interview, the facility failed to install self-closing devices per NFPA 101 (2012 edition), Life Safety Code, section 19.3.2.1.3 and 19.3.2.1.5. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 04/16/2024 between 9:15 AM and 1:00 PM, it was revealed by observation that room 531 was being used for storage of combustible supplies and did not have self-closing devices on the door. An interview with Maintenance Director verified this deficient finding at the time of discovery.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 49715 Based on observation, a review of available documentation, and staff interview, the facility failed to install proper protection for cooking equipment per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.5.1, 19.3.2.5.3 (9). This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 04/16/2024 between 9:15 AM and 1:00 PM, it was revealed by observation that a stove in the Clinic Area did not have a timer, not exceeding 120 minutes, that automatically deactivates the cooktop or range, independent of staff action. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 49715 Based on observation and staff interview, the facility failed to maintain the fire sprinkler systems per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 6.7.4. These deficient findings could have an isolated impact on residents within the facility. Findings include: On 04/16/2024 between 9:15 AM and 1:00 PM, it was revealed by observation that the main drain valves on the two dry sprinkler systems, and three wet sprinkler systems were not permanently marked with metal or plastic signs secured with corrosion resistant wire or chain. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 49715 Based on observation, the facility failed to maintain corridor doors per NFPA 101 (2012 edition), Life Safety Code, section 19.3.6.3.5. This deficient finding could have a pattewrened impact on the residents within the facility. Findings include: On 04/16/2024 between 9:15 AM and 1:00 PM, it was revealed by observations that the doors to patient rooms 112 and 116 did not latch when they were closed. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“Fundamentals - Building System Categories CFR(s): NFPA 101 Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99) This Standard is not met as evidenced by: 49715 Based on a review of available documentation and staff interview, the facility failed to provide a Risk Assessment per NFPA 99 (2012 edition), Health Care Facilities Code, section 4.2. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 04/16/2024 between 09:15 AM and 1:00 PM, it was revealed by a review of available documentation that the facility could not provide a NFPA 99 Risk Assessment for Chapters 5, 6, and 9 at the time of the survey. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 49715 Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, section 10.2.3 and 10.2.4, NFPA 101 (2012 edition), Life Safety Code, section 9.1.2, NFPA 70, (2011 edition), National Electrical Code, section 400.8. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 04/16/2024 between 9:15 AM and 1:00 PM, it was revealed observation there was an extension cord providing power to a charging unit for a mobile computer system in Room 169. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”