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Deficiency Records for St Francis Healthcare Center

A list of the most recent deficiencies for St Francis Healthcare Center. 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 Healthcare Center. 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?
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 2024-03-22 2024-05-02 N
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Health 2024-03-22 2024-05-02 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2024-03-29 2024-04-29 N
Address subsistence needs for staff and patients. Fire Safety 2024-03-29 2024-04-29 N
List the names and contact information of those in the facility. Fire Safety 2024-03-29 2024-04-29 N
Conduct testing and exercise requirements. Fire Safety 2024-03-29 2024-04-29 N
Use approved construction type or materials. Fire Safety 2024-03-29 2024-04-29 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2024-03-29 2024-04-29 N
Have properly located and lighted "Exit" signs. Fire Safety 2024-03-29 2024-04-29 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-03-29 2024-04-29 N
Properly provide smoke detection systems in areas open to corridors. Fire Safety 2024-03-29 2024-04-29 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-03-29 2024-04-29 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2024-03-29 2024-04-29 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-03-29 2024-04-29 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-03-29 2024-04-29 N
Meet requirements for the use of electrical equipment. Fire Safety 2024-03-29 2024-04-29 N
Prepare residents for a safe transfer or discharge from the nursing home. Health 2024-03-18 2024-04-18 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-11-14 2023-12-14 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-01-27 2022-03-17 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2022-01-27 2022-03-17 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-01-27 2022-03-17 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-01-27 2022-03-17 N
Provide and implement an infection prevention and control program. Health 2022-01-27 2022-03-17 N
Establish policies and procedures for medical documentation. Fire Safety 2022-02-08 2022-03-02 N
List the names and contact information of those in the facility. Fire Safety 2022-02-08 2022-03-02 N
Implement emergency and standby power systems. Fire Safety 2022-02-08 2022-03-02 N
Use approved construction type or materials. Fire Safety 2022-02-08 2022-03-02 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2022-02-08 2022-03-02 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 2022-02-08 2022-03-02 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2022-02-08 2022-03-02 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2022-02-08 2022-03-02 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2022-02-08 2022-03-02 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-02-08 2022-03-02 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-02-08 2022-03-02 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2022-02-08 2022-03-02 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-02-08 2022-03-02 N
Meet requirements for the use of electrical equipment. Fire Safety 2022-02-08 2022-03-02 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-02-08 2022-03-02 N
Have proper medical gas storage and administration areas. Fire Safety 2022-02-08 2022-03-02 N
Conduct testing and exercise requirements. Fire Safety 2019-06-06 2019-07-01 N
Use approved construction type or materials. Fire Safety 2019-06-06 2019-07-01 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2019-06-06 2019-07-01 N
Have properly located and lighted "Exit" signs. Fire Safety 2019-06-06 2019-07-01 N
Provide properly protected cooking facilities. Fire Safety 2019-06-06 2019-07-01 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2019-06-06 2019-07-01 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-06-06 2019-07-01 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2019-06-06 2019-07-01 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-06-06 2019-07-01 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2019-06-06 2019-07-01 N
Have simulated fire drills held at unexpected times. Fire Safety 2019-06-06 2019-07-01 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2019-06-06 2019-07-01 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-06-06 2019-07-01 N
Ensure proper usage of power strips and extension cords. Fire Safety 2019-06-06 2019-07-01 N
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Fire Safety 2019-06-06 2019-07-01 N
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2019-03-28 2019-04-25 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 2019-03-28 2019-04-25 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-03-28 2019-04-25 N
Provide and implement an infection prevention and control program. Health 2019-03-28 2019-04-25 N

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