A list of the most recent deficiencies for All Saints Healthcare Subacute. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-20 | 2023-11-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-20 | 2023-11-13 | 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 | 2023-10-20 | 2023-11-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-20 | 2023-11-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-20 | 2023-11-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-20 | 2023-11-13 | 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 | 2023-10-20 | 2023-11-13 | 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 | 2023-10-20 | 2023-11-13 | N |
| 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 | 2023-10-20 | 2023-11-13 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-10-20 | 2023-11-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-20 | 2023-11-13 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-10-20 | 2023-11-13 | 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 | 2023-10-20 | 2023-11-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-20 | 2023-11-13 | 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 | 2023-10-20 | 2023-11-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-20 | 2023-11-13 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-20 | 2023-11-13 | 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 | 2023-10-20 | 2023-11-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-20 | 2023-11-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-20 | 2023-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-20 | 2023-11-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-10-20 | 2023-11-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-20 | 2023-11-13 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-10-18 | 2023-11-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-18 | 2023-11-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-18 | 2023-11-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-18 | 2023-11-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-10-18 | 2023-11-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-18 | 2023-11-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-18 | 2023-11-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-31 | 2023-09-17 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-31 | 2023-09-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-12 | 2023-07-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-12 | 2023-07-29 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-05-24 | 2023-06-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-14 | 2023-03-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-14 | 2023-03-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-25 | 2023-02-03 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-31 | 2022-11-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-31 | 2022-11-25 | 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 | 2022-10-31 | 2022-11-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-31 | 2022-11-25 | 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 | 2022-10-31 | 2022-11-25 | N |
| 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 | 2022-10-31 | 2022-11-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-31 | 2022-11-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-31 | 2022-11-25 | 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 | 2022-10-31 | 2022-11-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-10-31 | 2022-11-25 | 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 | 2022-10-31 | 2022-11-25 | 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 | 2022-10-31 | 2022-11-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-31 | 2022-11-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-31 | 2022-11-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-31 | 2022-11-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-10-31 | 2022-11-25 | 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 | 2022-10-26 | 2022-11-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-26 | 2022-11-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-26 | 2022-11-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-26 | 2022-11-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-26 | 2022-11-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-26 | 2022-11-18 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-09-30 | 2022-10-31 | Y |
| 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 | 2022-08-22 | 2022-10-21 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-30 | 2022-10-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-30 | 2022-10-07 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-30 | 2022-10-07 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-09-13 | 2022-09-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-22 | 2022-09-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-22 | 2022-09-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-22 | 2022-09-02 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-22 | 2022-09-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-22 | 2022-09-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-18 | 2022-07-28 | Y |
| 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 | 2022-07-18 | 2022-07-28 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-05-26 | 2022-06-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-11 | 2022-05-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-29 | 2022-04-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-29 | 2022-04-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-29 | 2022-04-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-29 | 2022-04-07 | Y |
| Report COVID19 data to residents and families. | Health | 2022-02-14 | 2022-03-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-09 | 2022-02-22 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-05-26 | 2021-07-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-26 | 2021-07-06 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-26 | 2021-07-06 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-26 | 2021-07-06 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-05-26 | 2021-07-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-26 | 2021-07-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-09 | 2019-09-05 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-08-09 | 2019-09-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-08-09 | 2019-09-05 | N |
| 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 | 2019-08-09 | 2019-09-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-09 | 2019-09-05 | 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 | 2019-08-09 | 2019-09-05 | N |
| 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 | 2019-08-09 | 2019-09-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-09 | 2019-09-05 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-08-09 | 2019-09-05 | N |
| Post nurse staffing information every day. | Health | 2019-08-09 | 2019-09-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-09 | 2019-09-05 | 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 | 2019-08-09 | 2019-09-05 | 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 | 2019-08-09 | 2019-09-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-08-09 | 2019-09-05 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-08-15 | 2019-09-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-15 | 2019-09-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-15 | 2019-09-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-15 | 2019-09-05 | N |
