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Deficiency Records for Chi Franciscan Villa
A list of the most recent deficiencies for Chi Franciscan Villa. 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 Chi Franciscan Villa. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-20 | 2024-07-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-06-20 | 2024-07-05 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-30 | 2024-01-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-11-30 | 2024-01-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-30 | 2024-01-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-30 | 2024-01-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-05 | 2024-01-02 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-12-05 | 2024-01-02 | 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 | 2023-12-05 | 2024-01-02 | N |
| Post nurse staffing information every day. | Health | 2023-12-05 | 2024-01-02 | 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 | 2023-12-05 | 2024-01-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-05 | 2024-01-02 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-05 | 2024-01-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-05 | 2024-01-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-05 | 2024-01-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-05 | 2024-01-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-05 | 2024-01-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-05 | 2024-01-02 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-05 | 2024-01-02 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-12-05 | 2024-01-02 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-30 | 2023-12-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-30 | 2023-12-26 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-11-30 | 2023-12-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-30 | 2023-12-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-30 | 2023-12-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-30 | 2023-12-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-05 | 2023-09-15 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-07-12 | 2023-08-04 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-07-12 | 2023-08-04 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-07-12 | 2023-08-04 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-07-12 | 2023-08-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-12 | 2023-08-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-12 | 2023-07-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-04 | 2023-06-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-04 | 2023-06-01 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-08-25 | 2022-09-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-25 | 2022-09-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-25 | 2022-09-23 | 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 | 2022-08-25 | 2022-09-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-25 | 2022-09-23 | 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 | 2022-08-25 | 2022-09-23 | 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 | 2022-08-25 | 2022-09-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-25 | 2022-09-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-25 | 2022-09-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-08-25 | 2022-09-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-25 | 2022-09-23 | 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 | 2022-08-25 | 2022-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-25 | 2022-09-23 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-25 | 2022-09-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-25 | 2022-09-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-25 | 2022-09-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-25 | 2022-09-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-25 | 2022-09-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-25 | 2022-09-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-25 | 2022-09-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-09-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-25 | 2022-09-23 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-09 | 2022-09-23 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-08-09 | 2022-09-23 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-08-09 | 2022-09-23 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-08-09 | 2022-09-23 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-08-09 | 2022-09-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-09 | 2022-09-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-09 | 2022-09-23 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-08-09 | 2022-09-23 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-08-09 | 2022-09-23 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-08-09 | 2022-09-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-09 | 2022-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-09 | 2022-09-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-09 | 2022-09-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-09 | 2022-08-30 | 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 | 2022-08-09 | 2022-08-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-21 | 2022-05-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-21 | 2022-05-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-21 | 2022-05-19 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-01-06 | 2022-02-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-06 | 2022-02-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-06 | 2022-02-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-06 | 2022-02-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-08 | 2021-11-29 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-08 | 2021-11-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-26 | 2021-06-24 | 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 | 2021-05-26 | 2021-06-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-26 | 2021-06-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-26 | 2021-06-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-26 | 2021-06-24 | 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 | 2021-05-26 | 2021-06-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-26 | 2021-06-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-26 | 2021-06-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-24 | 2021-06-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-05-24 | 2021-06-24 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-05-24 | 2021-06-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-24 | 2021-06-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-24 | 2021-05-26 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-05-24 | 2021-05-26 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-11-30 | Not Fixed | N |
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