Care Citations

Chi Franciscan Villa

3601 S CHICAGO AVE, SOUTH MILWAUKEE, WI, 53172 · 4147644100

On the CMS record

Overall rating (CMS)
1 / 5
Health inspection rating
1 / 5
Staffing rating
1 / 5
Certified beds
90
Ownership type
Non profit - Other
Chain
COMMONSPIRIT HEALTH

Inspection findings on record (59)

Quoted exactly as CMS published them. We do not rewrite findings.

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity G · actual harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0814 · scope/severity F · potential for more than minimal harm

Dispose of garbage and refuse properly.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity E · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity D · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0693 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0805 · scope/severity D · potential for more than minimal harm

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity D · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0883 · scope/severity D · potential for more than minimal harm

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity G · actual harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity G · actual harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0725 · scope/severity F · potential for more than minimal harm

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0557 · scope/severity D · potential for more than minimal harm

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0585 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0676 · scope/severity D · potential for more than minimal harm

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0573 · scope/severity D · potential for more than minimal harm

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity G · actual harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity D · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity D · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity J · immediate jeopardy

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0602 · scope/severity E · potential for more than minimal harm

Protect each resident from the wrongful use of the resident's belongings or money.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity E · potential for more than minimal harm

Respond appropriately to all alleged violations.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0801 · scope/severity F · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity D · potential for more than minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity D · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0692 · scope/severity D · potential for more than minimal harm

Provide enough food/fluids to maintain a resident's health.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity D · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity G · actual harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity F · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity D · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity D · potential for more than minimal harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity D · potential for more than minimal harm

Provide safe and appropriate respiratory care for a resident when needed.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity J · immediate jeopardy

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity E · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0755 · scope/severity E · potential for more than minimal harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity D · potential for more than minimal harm

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity J · immediate jeopardy

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Administration Deficiencies

Tag 0851 · scope/severity F · potential for more than minimal harm

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity E · potential for more than minimal harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0554 · scope/severity D · potential for more than minimal harm

Allow residents to self-administer drugs if determined clinically appropriate.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0558 · scope/severity D · potential for more than minimal harm

Reasonably accommodate the needs and preferences of each resident.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0578 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity D · potential for more than minimal harm

Respond appropriately to all alleged violations.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0690 · scope/severity D · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0759 · scope/severity D · potential for more than minimal harm

Ensure medication error rates are not 5 percent or greater.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity D · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0732 · scope/severity C · potential for minimal harm

Post nurse staffing information every day.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0607 · scope/severity E · potential for more than minimal harm

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 525526