Deficiency Records for Clarence Tc Ching Villas at St Francis
Updated as of April 01, 2024
A list of the most recent deficiencies for Clarence Tc Ching Villas at 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-22 | 2024-01-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-22 | 2024-01-31 | 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 | 2023-12-22 | 2024-01-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-22 | 2024-01-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-22 | 2024-01-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-22 | 2024-01-31 | 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 | 2023-12-22 | 2024-01-31 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-12-22 | 2024-01-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-22 | 2024-01-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-22 | 2024-01-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-22 | 2024-01-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-26 | 2024-01-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-26 | 2024-01-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-26 | 2024-01-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-12-13 | 2023-01-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-13 | 2023-01-10 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-12-13 | 2023-01-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-09 | 2022-12-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-09 | 2022-12-27 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-12-09 | 2022-12-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-09 | 2022-12-27 | Y |
| 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 | 2022-12-09 | 2022-12-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-13 | 2022-11-11 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-13 | 2022-11-04 | Y |
| 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 | 2021-12-03 | 2022-01-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-03 | 2022-01-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-03 | 2022-01-15 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-03 | 2022-01-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-03 | 2022-01-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-03 | 2022-01-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-03 | 2022-01-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-03 | 2022-01-15 | 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 | 2021-12-03 | 2022-01-15 | 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 | 2021-12-03 | 2022-01-15 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-12-03 | 2022-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-03 | 2022-01-15 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2021-12-03 | 2022-01-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-03 | 2022-01-15 | Y |
| 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 | 2021-12-03 | 2022-01-15 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-16 | 2022-01-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-16 | 2022-01-14 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-12-16 | 2022-01-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-16 | 2022-01-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-16 | 2022-01-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-16 | 2022-01-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-24 | 2021-11-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-24 | 2021-11-08 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-09-24 | 2021-11-08 | Y |
