A list of the most recent deficiencies for St. Anne's Home. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-11-28 | 2023-12-22 | 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 | 2023-11-28 | 2023-12-22 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-11-28 | 2023-12-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-28 | 2023-12-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-28 | 2023-12-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-28 | 2023-12-22 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-11-17 | 2023-12-13 | N |
| Dispose of garbage and refuse properly. | Health | 2023-11-17 | 2023-12-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-17 | 2023-12-11 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-11-17 | 2023-12-03 | 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 | 2023-11-17 | 2023-11-17 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-11-17 | 2023-11-17 | N |
| Post nurse staffing information every day. | Health | 2023-11-17 | 2023-11-17 | 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 | 2023-11-17 | 2023-11-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-17 | 2022-01-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-17 | 2022-01-07 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-12-17 | 2022-01-07 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-12-17 | 2022-01-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-17 | 2022-01-07 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-12-21 | 2022-01-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-21 | 2022-01-05 | 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 | 2019-03-25 | 2019-05-10 | 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 | 2019-03-25 | 2019-05-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-25 | 2019-05-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-03-25 | 2019-05-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-11 | 2019-04-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-11 | 2019-04-29 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-04-11 | 2019-04-29 | N |
