Deficiency Records for Chi Health St Francis

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Updated as of February 01, 2024

A list of the most recent deficiencies for Chi Health 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?
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2023-03-13 2023-04-20 N
Have enough outside ventilation via a window or mechanical ventilation, or both. Health 2023-03-13 2023-04-20 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2023-03-14 2023-04-20 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 2021-11-15 2021-12-07 N
Provide and implement an infection prevention and control program. Health 2021-11-15 2021-12-07 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2020-01-06 2020-02-13 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 2020-01-06 2020-02-13 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2020-01-06 2020-02-13 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2020-01-06 2020-02-13 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2020-01-06 2020-02-13 N
Ensure each resident receives an accurate assessment. Health 2020-01-06 2020-02-13 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2020-01-06 2020-02-13 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 2020-01-06 2020-02-13 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2020-01-06 2020-02-13 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 2020-01-06 2020-02-13 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 2020-01-06 2020-02-13 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-01-06 2020-02-13 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2020-01-06 2020-02-13 N
Provide and implement an infection prevention and control program. Health 2020-01-06 2020-02-13 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2020-01-02 2020-02-13 N