Deficiency Records for Villa St Francis Catholic Care Center Inc
Updated as of April 01, 2024
A list of the most recent deficiencies for Villa St Francis Catholic Care Center Inc. 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 care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-27 | 2023-09-04 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-06-07 | 2023-07-12 | N |
| Use approved construction type or materials. | Fire Safety | 2023-06-07 | 2023-07-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-07 | 2023-07-12 | 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 | 2023-06-07 | 2023-07-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-07 | 2023-07-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-07 | 2023-07-12 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-06-07 | 2023-07-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-07 | 2023-07-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-07 | 2023-07-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-07 | 2023-07-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-07 | 2023-07-12 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-06-07 | 2023-07-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-07 | 2023-07-12 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-06-07 | 2023-07-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-23 | 2023-06-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-23 | 2023-06-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-23 | 2023-06-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-05-23 | 2023-06-26 | 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 | 2023-05-23 | 2023-06-26 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-05-23 | 2023-06-26 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-05-23 | 2023-06-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-23 | 2023-06-26 | N |
| Use approved construction type or materials. | Fire Safety | 2021-11-03 | 2021-12-08 | 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 | 2021-11-03 | 2021-12-08 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-11-03 | 2021-12-08 | 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 | 2021-11-03 | 2021-12-08 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2021-11-03 | 2021-12-08 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-09-27 | 2021-10-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-27 | 2021-10-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-27 | 2021-10-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-09-27 | 2021-10-26 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-09-27 | 2021-10-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-27 | 2021-10-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-27 | 2021-10-26 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-04-30 | 2021-05-28 | Y |
| Have proper power supply for life support equipment. | Fire Safety | 2021-04-30 | 2021-05-28 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-30 | 2021-05-28 | 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 | 2019-11-07 | 2019-12-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-11-07 | 2019-12-06 | 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 | 2019-11-07 | 2019-12-06 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-11-07 | 2019-12-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-07 | 2019-12-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-07 | 2019-12-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-22 | 2019-09-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-22 | 2019-09-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-22 | 2019-09-23 | N |
