CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Chi Franciscan Villa
View the most recent health deficiencies and inspection results for Chi Franciscan Villa. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Chi Franciscan Villa. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2026-02-18 | 2026-03-16 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2026-02-18 | 2026-03-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-02-18 | 2026-03-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2026-02-18 | 2026-03-16 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2026-02-18 | 2026-03-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2026-02-18 | 2026-03-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2026-02-18 | 2026-03-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-02-18 | 2026-03-16 | 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 | 2026-02-18 | 2026-03-16 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2025-12-23 | 2026-01-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-10-17 | 2025-12-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-11-13 | 2025-12-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-10-17 | 2025-12-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-10-17 | 2025-12-05 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2025-07-16 | 2025-08-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-07-16 | 2025-07-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-07-16 | 2025-07-17 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2025-05-30 | 2025-06-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-05-30 | 2025-06-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-05-30 | 2025-06-30 | Y |
| 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 | 2025-05-30 | 2025-06-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-05-30 | 2025-06-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-07-16 | 2025-06-12 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2025-02-20 | 2025-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-02-20 | 2025-03-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-02-20 | 2025-03-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2025-02-20 | 2025-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-02-20 | 2025-03-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2025-02-20 | 2025-03-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-02-20 | 2025-03-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2025-02-20 | 2025-03-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2025-02-20 | 2025-03-20 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2025-02-20 | 2025-03-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2025-02-20 | 2025-03-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2025-02-20 | 2025-03-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-02-20 | 2025-03-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-02-20 | 2025-02-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-02-20 | 2025-02-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-02-20 | 2025-02-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-02-20 | 2025-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-02-20 | 2025-02-28 | 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 | 2025-02-20 | 2025-02-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-02-20 | 2025-02-27 | N |
| Construct fire resistant interior walls. | Fire Safety | 2025-02-20 | 2025-02-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2025-02-20 | 2025-02-27 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-12-05 | 2024-12-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-11-08 | 2024-11-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-11-08 | 2024-11-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-06-20 | 2024-07-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-20 | 2024-07-05 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-12-05 | 2024-01-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-05 | 2024-01-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-05 | 2024-01-11 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-12-05 | 2024-01-02 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-05 | 2024-01-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-05 | 2024-01-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-05 | 2024-01-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-05 | 2024-01-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-05 | 2024-01-02 | 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 | 2023-12-05 | 2024-01-02 | 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 | 2023-12-05 | 2024-01-02 | N |
| Post nurse staffing information every day. | Health | 2023-12-05 | 2024-01-02 | 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 | 2023-12-05 | 2024-01-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-05 | 2024-01-02 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-05 | 2024-01-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-05 | 2024-01-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-05 | 2024-01-02 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-05 | 2023-12-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-05 | 2023-12-27 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-12-05 | 2023-12-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-05 | 2023-12-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-12-05 | 2023-12-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-05 | 2023-12-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-12-05 | 2023-12-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-05 | 2023-09-15 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-07-12 | 2023-08-04 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-07-12 | 2023-08-04 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-07-12 | 2023-08-04 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-07-12 | 2023-08-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-12 | 2023-08-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-12 | 2023-07-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-04 | 2023-06-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-04 | 2023-06-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-25 | 2022-09-23 | N |
| Respond appropriately to all alleged violations. | Health | 2022-08-25 | 2022-09-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-25 | 2022-09-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-25 | 2022-09-23 | 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 | 2022-08-25 | 2022-09-23 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-25 | 2022-09-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-25 | 2022-09-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-25 | 2022-09-23 | N |
| 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 | 2022-08-25 | 2022-09-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-09-23 | 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 | 2022-08-25 | 2022-09-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-25 | 2022-09-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-25 | 2022-09-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-25 | 2022-09-23 | 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 | 2022-08-25 | 2022-09-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-25 | 2022-09-23 | 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 | 2022-08-25 | 2022-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-25 | 2022-09-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-25 | 2022-09-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-25 | 2022-09-23 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-08-25 | 2022-09-23 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-08-25 | 2022-09-23 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-08-25 | 2022-09-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-25 | 2022-09-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-25 | 2022-09-23 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-08-25 | 2022-09-23 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-08-25 | 2022-09-23 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-08-25 | 2022-09-23 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-08-25 | 2022-09-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-25 | 2022-09-23 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-08-25 | 2022-09-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-25 | 2022-09-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-25 | 2022-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-25 | 2022-09-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-25 | 2022-09-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-25 | 2022-08-30 | 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 | 2022-08-25 | 2022-08-10 | N |