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Deficiency Records for Optalis Health and Rehabilitation St Francis
A list of the most recent deficiencies for Optalis Health and Rehabilitation 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 Optalis Health and Rehabilitation 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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2024-01-31 | 2024-02-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-31 | 2024-02-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-31 | 2024-02-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-31 | 2024-02-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-31 | 2024-02-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-31 | 2024-02-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-31 | 2024-02-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-31 | 2024-02-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-31 | 2024-02-21 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-26 | 2023-06-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-20 | 2022-11-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-20 | 2022-11-21 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-10-20 | 2022-11-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-20 | 2022-11-21 | 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 | 2022-10-20 | 2022-11-21 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-10-20 | 2022-11-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-20 | 2022-11-21 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-10-20 | 2022-11-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-20 | 2022-11-21 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-10-20 | 2022-11-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-20 | 2022-11-21 | 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 | 2022-10-20 | 2022-11-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-10-20 | 2022-11-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-20 | 2022-11-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-20 | 2022-11-21 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-19 | 2022-11-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-19 | 2022-11-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-10-19 | 2022-11-21 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-10-19 | 2022-11-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-19 | 2022-11-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-19 | 2022-11-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-10-19 | 2022-11-21 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-10-19 | 2022-11-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-19 | 2022-11-21 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-10-19 | 2022-11-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-19 | 2022-11-21 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-10-19 | 2022-11-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-19 | 2022-11-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-24 | 2021-08-13 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-06-24 | 2021-07-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-24 | 2021-07-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-24 | 2021-07-26 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-06-24 | 2021-07-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-24 | 2021-07-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-06-24 | 2021-07-26 | 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 | 2021-06-24 | 2021-07-26 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-06-24 | 2021-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-24 | 2021-07-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-24 | 2021-07-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-24 | 2021-07-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-24 | 2021-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-24 | 2021-07-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-06-24 | 2021-07-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-24 | 2021-07-26 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-06-24 | 2021-07-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-24 | 2021-07-26 | N |
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