Deficiency Records for Chi Health St Francis
Updated as of June 01, 2021
This is not the most recent data for Chi Health St Francis. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2020-06-19 | 2020-07-22 | 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 |
| 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 |
| 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 | 2018-09-27 | 2018-11-09 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-09-27 | 2018-11-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-27 | 2018-11-09 | 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 | 2018-09-27 | 2018-11-09 | 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 | 2018-09-27 | 2018-11-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-27 | 2018-11-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-27 | 2018-11-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-09-27 | 2018-11-09 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-08-22 | 2017-10-21 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-08-22 | 2017-10-21 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-22 | 2017-10-21 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-08-21 | 2017-09-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-08-21 | 2017-09-29 | N |
