A list of the most recent deficiencies for St. John of God Retirement. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-05 | 2024-01-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-05 | 2024-01-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-21 | 2024-01-08 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-10-02 | 2023-11-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-04 | 2023-10-27 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-10-04 | 2023-10-27 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-10-04 | 2023-10-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-04 | 2023-10-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-04 | 2023-10-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-04 | 2023-10-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-04 | 2023-10-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-04 | 2023-10-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-04 | 2023-10-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-02 | 2023-10-26 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-10-02 | 2023-10-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-02 | 2023-10-26 | 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 | 2023-10-02 | 2023-10-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-02 | 2023-10-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-02 | 2023-10-26 | 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 | 2023-10-02 | 2023-10-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-02 | 2023-10-26 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-10-02 | 2023-10-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-02 | 2023-10-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-02 | 2023-10-26 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-02 | 2023-10-26 | 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 | 2023-08-24 | 2023-09-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-24 | 2023-09-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-20 | 2023-04-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-06 | 2023-02-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-02 | 2023-02-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-15 | 2022-10-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-17 | 2022-07-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-13 | 2022-06-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-03 | 2022-05-27 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-06-01 | 2021-08-25 | 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 | 2021-06-01 | 2021-08-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-01 | 2021-08-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-01 | 2021-07-30 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2021-06-01 | 2021-07-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-01 | 2021-06-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-06-01 | 2021-06-29 | 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 | 2021-06-01 | 2021-06-29 | 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 | 2021-06-01 | 2021-06-29 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-01 | 2021-06-29 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-06-01 | 2021-06-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-01 | 2021-06-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-01 | 2021-06-29 | 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 | 2021-06-01 | 2021-06-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-01 | 2021-06-29 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-06-01 | 2021-06-29 | N |
| Provide activities to meet all resident's needs. | Health | 2021-06-01 | 2021-06-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-01 | 2021-06-29 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-06-01 | 2021-06-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-01 | 2021-06-29 | 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 | 2021-06-01 | 2021-06-29 | 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 | 2021-06-01 | 2021-06-29 | 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 | 2021-06-01 | 2021-06-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-01 | 2021-06-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-01 | 2021-06-29 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-06-01 | 2021-06-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-01 | 2021-06-29 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-06-01 | 2021-06-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-06-08 | 2021-06-29 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-06-08 | 2021-06-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-08 | 2021-06-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-25 | 2021-06-18 | Y |
| 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 | 2021-04-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-24 | 2021-04-03 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-14 | 2020-01-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-12-14 | 2020-01-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-14 | 2020-01-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-12-14 | 2020-01-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-12-14 | 2020-01-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-14 | 2020-01-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-14 | 2020-01-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-11 | 2020-01-10 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-12-11 | 2020-01-10 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-12-11 | 2020-01-10 | 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 | 2019-12-11 | 2020-01-10 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-12-11 | 2020-01-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-11 | 2020-01-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-11 | 2020-01-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-11 | 2020-01-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-11 | 2020-01-10 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-12-11 | 2020-01-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-11 | 2020-01-10 | 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 | 2019-12-11 | 2020-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-11 | 2020-01-10 | N |
