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Deficiency Records for Clarence Tc Ching Villas at St Francis
A list of the most recent deficiencies for Clarence Tc Ching Villas at St Francis. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Clarence Tc Ching Villas at St Francis. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-12-13 | 2025-01-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-12-13 | 2025-01-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-12-13 | 2025-01-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-12-13 | 2025-01-23 | N |
| 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. | Health | 2024-12-13 | 2025-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-12-13 | 2025-01-23 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-12-13 | 2025-01-23 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-12-13 | 2025-01-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-12-13 | 2025-01-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-12-13 | 2025-01-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-12-13 | 2025-01-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-12-13 | 2025-01-23 | N |
| 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. | Health | 2024-12-13 | 2025-01-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-12-13 | 2025-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-12-13 | 2025-01-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-12-16 | 2025-01-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-23 | 2024-06-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-22 | 2024-01-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-22 | 2024-01-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-22 | 2024-01-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-22 | 2024-01-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-22 | 2024-01-31 | N |
| 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. | Health | 2023-12-22 | 2024-01-31 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-12-22 | 2024-01-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-22 | 2024-01-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-22 | 2024-01-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-22 | 2024-01-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-22 | 2024-01-31 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-26 | 2024-01-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-26 | 2024-01-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-26 | 2024-01-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-12-13 | 2023-01-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-13 | 2023-01-10 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-12-13 | 2023-01-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-09 | 2022-12-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-09 | 2022-12-27 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-12-09 | 2022-12-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-09 | 2022-12-27 | Y |
| 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. | Health | 2022-12-09 | 2022-12-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-13 | 2022-11-11 | Y |
| 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. | Health | 2022-10-13 | 2022-11-04 | Y |
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