A list of the most recent deficiencies for St Joseph's Center. 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 | 2023-09-25 | 2023-10-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-10 | 2023-08-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-23 | 2023-05-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-23 | 2023-05-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-23 | 2023-05-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-07 | 2023-03-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-07 | 2023-03-20 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-02-07 | 2023-03-20 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-10-19 | 2022-12-08 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-10-19 | 2022-12-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-19 | 2022-12-08 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-09 | 2022-09-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-09 | 2022-09-19 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-08-09 | 2022-09-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-09 | 2022-09-19 | 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 | 2022-08-09 | 2022-09-19 | 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 | 2022-08-09 | 2022-09-19 | 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 | 2022-08-09 | 2022-09-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-09 | 2022-09-19 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-08-09 | 2022-09-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-13 | 2022-07-29 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-13 | 2022-07-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-13 | 2022-07-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-13 | 2022-07-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-13 | 2022-07-29 | Y |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2020-01-08 | 2021-06-03 | 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 | 2020-01-08 | 2021-03-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-08 | 2021-03-19 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2020-01-08 | 2021-03-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-09 | 2020-02-20 | 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 | 2020-01-09 | 2020-02-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-09 | 2020-02-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-09 | 2020-02-20 | 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 | 2020-01-09 | 2020-02-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-09 | 2020-02-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-10-31 | 2018-12-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-11-05 | 2018-12-12 | 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 | 2018-11-05 | 2018-12-12 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-11-05 | 2018-12-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-05 | 2018-12-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-05 | 2018-12-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-05 | 2018-12-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-11-05 | 2018-12-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-11-05 | 2018-12-12 | 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 | 2018-11-05 | 2018-12-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-05 | 2018-12-12 | N |
| Dispose of garbage and refuse properly. | Health | 2018-11-05 | 2018-12-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-05 | 2018-12-12 | N |
| Keep all essential equipment working safely. | Health | 2018-11-05 | 2018-12-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-11-05 | 2018-12-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-31 | 2018-12-12 | N |
