A list of the most recent deficiencies for Ascension Villa Franciscan. 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? |
|---|---|---|---|---|
| Provide appropriate foot care. | Health | 2023-12-27 | 2024-02-05 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-18 | 2023-12-30 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-10-18 | 2023-10-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-18 | 2023-10-31 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-10-06 | 2023-10-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-06 | 2023-10-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-06 | 2023-10-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-06 | 2023-10-29 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-10-06 | 2023-10-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-06 | 2023-10-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-06 | 2023-10-29 | 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 | 2023-10-06 | 2023-10-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-06 | 2023-10-29 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-10-18 | 2023-10-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-18 | 2023-10-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-10-18 | 2023-10-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-14 | 2023-10-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-16 | 2023-07-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-16 | 2023-07-05 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-21 | 2023-03-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-09 | 2023-03-13 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-15 | 2023-01-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-15 | 2023-01-16 | N |
| Provide appropriate foot care. | Health | 2022-12-15 | 2023-01-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-15 | 2023-01-16 | 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 | 2022-12-15 | 2023-01-16 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-12-15 | 2023-01-16 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-12-15 | 2023-01-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-15 | 2023-01-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-12-15 | 2023-01-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-15 | 2023-01-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-15 | 2022-12-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-19 | 2022-05-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-08 | 2022-04-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-28 | 2022-03-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-28 | 2022-03-17 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-09-01 | 2021-09-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-01 | 2021-09-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-09-01 | 2021-09-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-01 | 2021-09-22 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-09-01 | 2021-09-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-09-01 | 2021-09-17 | 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 | 2021-09-01 | 2021-09-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-01 | 2021-09-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-01 | 2021-09-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-09-01 | 2021-09-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-01 | 2021-09-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-09-01 | 2021-09-17 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-09-01 | 2021-09-17 | 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 | 2021-08-26 | 2021-09-15 | N |
| 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 | 2021-08-26 | 2021-09-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-26 | 2021-09-15 | 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 | 2021-08-26 | 2021-09-15 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-08-26 | 2021-09-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-26 | 2021-09-15 | 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 | 2021-08-26 | 2021-09-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-26 | 2021-09-15 | N |
