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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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-26 | 2024-10-07 | Y |
| 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 |
| 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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