A list of the most recent deficiencies for Franciscan Woods. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-05 | 2023-11-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-05 | 2023-11-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-05 | 2023-11-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-05 | 2023-11-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-05 | 2023-11-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-05 | 2023-11-04 | Y |
| 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 | 2023-10-05 | 2023-11-04 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-03 | 2023-11-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-03 | 2023-11-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-03 | 2023-11-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-07 | 2023-04-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-17 | 2023-02-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-17 | 2023-02-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-17 | 2023-02-17 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-07-18 | 2022-08-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-18 | 2022-08-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-18 | 2022-08-16 | N |
| Respond appropriately to all alleged violations. | Health | 2022-07-18 | 2022-08-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-18 | 2022-08-16 | 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 | 2022-07-18 | 2022-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-18 | 2022-08-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-18 | 2022-08-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-07-18 | 2022-08-16 | 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 | 2022-07-18 | 2022-08-16 | 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 | 2022-07-18 | 2022-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-18 | 2022-08-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-18 | 2022-08-16 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-07-18 | 2022-08-16 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-07-18 | 2022-08-16 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-13 | 2022-08-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-13 | 2022-08-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-14 | 2021-11-13 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-30 | 2021-10-30 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-09-30 | 2021-10-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-07 | 2021-05-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-07 | 2021-05-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-07 | 2021-05-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-07 | 2021-05-13 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-04-06 | 2021-04-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-06 | 2021-04-19 | N |
