Inspection·April 10, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of the facility Self-Reported Incidents (SRIs), staff interview and review of facility policy, the facility failed to ensure staff implemented the facility's abuse policy related to immediate reporting of allegations of abuse to the Administrator. This affected one (#32) of one resident reviewed for abuse. The facility census was 52. Residents Affected - Few Findings include: Review of Resident #32's medical record revealed an admission date of 07/28/23. Diagnoses including phantom limb syndrome with pain, chronic respiratory failure, and acquired absence of left leg above the knee. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/21/25, revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating Resident #32 was cognitively intact. Review of the facility submitted SRI, created 01/26/25, revealed on 01/25/25, Resident #32 reported to Certified Nursing Assistant (CNA) #310 and Licensed Practical Nurse (LPN) #315 that at approximately 1:30 A.M., an unidentified staff member used force while applying cream to his left lower extremity (LLE) stump and, while providing incontinence care, it felt like the staff inserted a digit into his rectum. Further review of the SRI revealed LPN #315 did not report the alleged abuse to the facility administration until 01/26/25. At the time LPN #315 reported the alleged abuse, the facility immediately began an investigation, made appropriate notifications, and suspended the possible staff members pending the results of the facility investigation. Interview on 04/10/25 at 2:02 P.M. with the Director of Nursing (DON) confirmed Resident #32 initially reported an allegation of abuse to LPN #315 on 01/25/25, but LPN #315 did not report it to administration until the resident made the allegation a second time on 01/26/24. Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated 11/21/24, revealed all alleged violations would be reported to the Administrator immediately, but not later than two hours after the allegation was made. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366102 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)