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Deficiency Records for St Francis Home
A list of the most recent deficiencies for St Francis Home. 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 St Francis Home. 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? |
|---|---|---|---|---|
| Install proper backup exit lighting. | Fire Safety | 2024-12-18 | 2025-02-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-12-18 | 2025-01-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-12-18 | 2025-01-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-12-18 | 2025-01-31 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-12-18 | 2025-01-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-12-18 | 2025-01-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-12-18 | 2025-01-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-12-18 | 2025-01-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-12-18 | 2025-01-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-12-18 | 2025-01-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-12-18 | 2025-01-31 | 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 | 2024-12-18 | 2025-01-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-12-18 | 2025-01-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-12-18 | 2025-01-18 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-12-18 | 2025-01-18 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2024-12-18 | 2025-01-18 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-12-18 | 2025-01-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-29 | 2024-08-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-29 | 2024-08-29 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-09-13 | 2024-02-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-11 | 2024-02-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-09 | 2023-12-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-09 | 2023-12-09 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-13 | 2023-11-08 | 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 | 2023-09-13 | 2023-10-20 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-09-13 | 2023-10-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-13 | 2023-10-13 | 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 | 2023-09-13 | 2023-10-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-13 | 2023-10-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-13 | 2023-10-13 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-09-13 | 2023-09-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-09-13 | 2023-09-15 | 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 | 2023-09-13 | 2023-09-15 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-09-13 | 2023-09-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-10 | 2023-08-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-10 | 2023-08-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-10 | 2023-08-02 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-06 | 2022-11-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-05 | 2022-11-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-05 | 2022-11-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-05 | 2022-11-05 | Y |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-10-06 | 2022-11-05 | N |
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