A list of the most recent deficiencies for Jan Frances Care 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 a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-12-07 | 2024-01-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-13 | 2023-08-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-13 | 2023-08-01 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-01-26 | 2023-03-05 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-01-26 | 2023-03-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-13 | 2022-11-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-12 | 2022-11-22 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-14 | 2022-10-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-14 | 2022-10-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-19 | 2022-10-14 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-09-19 | 2022-10-14 | 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 | 2022-09-19 | 2022-10-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-19 | 2022-10-14 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2022-09-19 | 2022-10-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-19 | 2022-10-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-19 | 2022-10-14 | 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 | 2022-09-19 | 2022-10-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-19 | 2022-10-14 | 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 | 2022-09-19 | 2022-10-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-19 | 2022-10-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-19 | 2022-10-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-19 | 2022-10-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-19 | 2022-10-14 | 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 | 2022-09-19 | 2022-10-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-19 | 2022-10-14 | 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 | 2022-09-19 | 2022-10-14 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-09-19 | 2022-10-14 | 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 | 2022-09-19 | 2022-10-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-19 | 2022-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-19 | 2022-10-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-19 | 2022-10-14 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2022-09-19 | 2022-10-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-19 | 2022-10-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-19 | 2022-10-14 | 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 | 2022-09-19 | 2022-10-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-19 | 2022-10-14 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-09-19 | 2022-10-14 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-14 | 2022-10-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-14 | 2022-10-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-14 | 2022-10-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-14 | 2022-10-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-14 | 2022-10-14 | 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 | 2022-09-12 | 2022-10-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-12 | 2022-10-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-12 | 2022-10-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-12 | 2022-10-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-12 | 2022-10-12 | 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 | 2022-04-19 | 2022-06-16 | Y |
| 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 | 2022-04-19 | 2022-05-31 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-19 | 2022-05-31 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-19 | 2022-05-01 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-04-19 | 2022-05-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-09 | 2021-09-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-09 | 2021-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-09 | 2021-09-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-24 | 2021-03-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-12-04 | 2020-01-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-04 | 2020-01-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-12-04 | 2020-01-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-04 | 2020-01-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-12-04 | 2020-01-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-04 | 2020-01-15 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-11-08 | 2018-12-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-08 | 2018-12-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-08 | Not Fixed | N |
