Deficiency Records for Wheaton Franciscan Hc - Terrace at St Francis
Updated as of March 01, 2024
A list of the most recent deficiencies for Wheaton Franciscan Hc - Terrace at 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-17 | 2024-02-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-17 | 2024-02-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-17 | 2024-02-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-17 | 2024-02-16 | Y |
| 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 | 2024-01-17 | 2024-02-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-17 | 2024-02-16 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-01-17 | 2024-02-16 | 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 | 2024-01-17 | 2024-02-16 | 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 | 2023-11-05 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-05 | 2023-11-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-05 | 2023-11-05 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-01 | 2023-05-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-01 | 2023-05-18 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-04-01 | 2023-05-18 | Y |
| Assess the resident when there is a significant change in condition | Health | 2023-04-01 | 2023-05-18 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-04-01 | 2023-05-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-01 | 2023-05-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-01 | 2023-05-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-01 | 2023-05-18 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-04-01 | 2023-05-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-01 | 2023-05-18 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-01 | 2023-05-18 | Y |
| Install proper backup exit lighting. | Fire Safety | 2023-03-28 | 2023-05-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-28 | 2023-05-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-28 | 2023-05-04 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-03-28 | 2023-05-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-28 | 2023-05-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-28 | 2023-05-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-06 | 2022-11-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-06 | 2022-11-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-06 | 2022-11-03 | 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 | 2022-10-06 | 2022-10-29 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-01-06 | 2022-02-06 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-01-06 | 2022-02-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-06 | 2022-02-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-06 | 2022-02-06 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| 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 | 2022-01-04 | 2022-02-06 | 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 | 2022-01-04 | 2022-02-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-27 | 2021-11-25 | 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 | 2019-12-18 | 2020-01-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-18 | 2020-01-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-18 | 2020-01-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-18 | 2020-01-18 | N |
