Deficiency Records for The Gardens of St. Francis
Updated as of July 01, 2022
This is not the most recent data for The Gardens of St. Francis. For the most recent information, click here.
A list of the most recent deficiencies for The Gardens of 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? |
---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-08 | 2021-10-15 | N |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-09-08 | 2021-10-15 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-08 | 2021-10-15 | 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 | 2021-09-08 | 2021-10-15 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-08 | 2021-10-15 | 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 | 2021-09-08 | 2021-10-15 | N |
Ensure each resident receives an accurate assessment. | Health | 2021-09-08 | 2021-10-15 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-08 | 2021-10-15 | 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 | 2021-09-08 | 2021-10-15 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-08 | 2021-10-15 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-08 | 2021-10-15 | N |
Assist a resident in gaining access to vision and hearing services. | Health | 2021-09-08 | 2021-10-15 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-08 | 2021-10-15 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-08 | 2021-10-15 | 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 | 2021-09-08 | 2021-10-15 | 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 | 2021-09-08 | 2021-10-15 | 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 | 2021-09-08 | 2021-10-15 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-08 | 2021-10-15 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-08 | 2021-10-15 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-08 | 2021-10-15 | N |
Perform COVID19 testing on residents and staff. | Health | 2021-09-08 | 2021-10-15 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-08 | 2021-10-15 | Y |
Provide and implement an infection prevention and control program. | Health | 2021-09-08 | 2021-10-15 | Y |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-30 | 2021-10-15 | N |
Have restrictions on the use of flammable curtains. | Fire Safety | 2021-08-30 | 2021-10-15 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-30 | 2021-10-15 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-02 | 2021-09-08 | Y |
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2021-08-02 | 2021-09-08 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-04 | 2021-05-28 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-04 | 2021-05-28 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-04 | 2021-05-28 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-04 | 2021-05-28 | Y |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-04 | 2021-05-28 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-04 | 2021-05-28 | Y |
Implement a program that monitors antibiotic use. | Health | 2021-05-04 | 2021-05-28 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-11-17 | 2020-12-16 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-11-17 | 2020-12-16 | Y |
Provide and implement an infection prevention and control program. | Health | 2020-11-17 | 2020-12-16 | Y |
Assure the security of all personal funds of residents deposited with the facility. | Health | 2020-02-20 | 2020-03-25 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-20 | 2020-03-25 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-20 | 2020-03-25 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-20 | 2020-03-25 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-20 | 2020-03-25 | 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 | 2020-02-21 | 2020-03-25 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-21 | 2020-03-25 | N |
Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2020-02-21 | 2020-03-25 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-29 | 2019-09-13 | Y |
Establish policies and procedures for volunteers. | Fire Safety | 2018-12-29 | 2019-01-11 | N |
Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-12-29 | 2019-01-11 | N |
Provide emergency officials' contact information. | Fire Safety | 2018-12-29 | 2019-01-11 | N |
Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-12-29 | 2019-01-11 | N |
Provide properly protected cooking facilities. | Fire Safety | 2018-12-29 | 2019-01-11 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-12-29 | 2019-01-11 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2018-12-29 | 2019-01-11 | N |
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2018-12-28 | 2019-01-09 | N |