A list of the most recent deficiencies for Franciscan Health 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? |
|---|---|---|---|---|
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-10-05 | 2023-11-22 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-10-05 | 2023-11-22 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2023-10-05 | 2023-11-22 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-10-05 | 2023-11-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-05 | 2023-11-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-05 | 2023-11-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-05 | 2023-11-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-05 | 2023-11-22 | 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 | 2023-10-05 | 2023-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-05 | 2023-11-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-03 | 2023-11-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-03 | 2023-11-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-03 | 2023-11-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-01 | 2023-03-24 | 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 | 2023-01-06 | 2023-02-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-06 | 2023-02-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-06 | 2023-02-18 | 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 | 2023-01-06 | 2023-02-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-06 | 2023-02-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-06 | 2023-02-18 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-01-06 | 2023-02-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-06 | 2023-02-18 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-01-06 | 2023-02-18 | 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 | 2023-01-04 | 2023-02-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-04 | 2023-02-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-04 | 2023-02-18 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-01-04 | 2023-02-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-04 | 2023-02-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-04 | 2023-02-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-19 | 2022-09-24 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-07-13 | 2022-08-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-13 | 2022-08-15 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-02-14 | 2022-03-15 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-29 | 2021-12-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-29 | 2021-12-17 | 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 | 2021-10-29 | 2021-12-17 | 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 | 2021-10-29 | 2021-12-17 | 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 | 2021-10-29 | 2021-12-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-10-29 | 2021-12-17 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-10-29 | 2021-12-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-10-29 | 2021-12-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-10-29 | 2021-12-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-27 | 2021-12-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-27 | 2021-12-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-27 | 2021-12-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-27 | 2021-12-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-27 | 2021-12-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-01 | 2021-07-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-01 | 2021-07-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-01 | 2021-07-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-19 | 2021-06-27 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-05-19 | 2021-06-27 | 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 | 2021-05-19 | 2021-06-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-19 | 2021-06-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-19 | 2021-06-27 | Y |
| 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 | 2021-05-19 | 2021-06-27 | Y |