A list of the most recent deficiencies for St Francis Senior Ministries. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-16 | 2023-04-17 | 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 | 2023-03-16 | 2023-04-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-16 | 2023-04-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-04-17 | 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 | 2023-03-16 | 2023-04-17 | 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 | 2023-03-16 | 2023-04-17 | 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 | 2023-03-16 | 2023-04-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-16 | 2023-04-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-16 | 2023-04-17 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-03-16 | 2023-04-17 | Y |
| 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 | 2023-03-13 | 2023-04-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-13 | 2023-04-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-13 | 2023-04-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-13 | 2023-04-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-13 | 2023-04-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-13 | 2023-04-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-04 | 2022-05-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-04 | 2022-05-22 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-05-04 | 2022-05-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-04 | 2022-05-22 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-05-18 | 2021-06-08 | Y |
| 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 | 2019-09-19 | 2019-11-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-19 | 2019-11-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-19 | 2019-11-01 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-19 | 2019-11-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-19 | 2019-11-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-09-19 | 2019-11-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-09-19 | 2019-11-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-19 | 2019-11-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-19 | 2019-11-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-09-19 | 2019-11-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-19 | 2019-11-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-19 | 2019-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-19 | 2019-11-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-19 | 2019-11-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-19 | 2019-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-23 | 2018-10-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-08-23 | 2018-10-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-23 | 2018-10-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-08-20 | 2018-10-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-08-20 | 2018-10-05 | N |
