A list of the most recent deficiencies for Saint John Paul I I 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? |
|---|---|---|---|---|
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-05-17 | 2023-06-23 | 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 | 2023-05-17 | 2023-06-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-17 | 2023-06-23 | 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 | 2023-05-17 | 2023-06-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-17 | 2023-06-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-05-17 | 2023-06-23 | 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 | 2023-05-17 | 2023-06-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-17 | 2023-06-23 | 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 | 2023-05-17 | 2023-06-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-17 | 2023-06-23 | 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 | 2023-05-17 | 2023-06-23 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-05-17 | 2023-06-23 | N |
| Post nurse staffing information every day. | Health | 2023-05-17 | 2023-06-23 | 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 | 2023-05-17 | 2023-06-23 | 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 | 2023-05-17 | 2023-06-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-17 | 2023-06-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-17 | 2023-06-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-17 | 2023-06-23 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-05-17 | 2023-06-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-10 | 2023-06-21 | 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 | 2023-05-10 | 2023-06-21 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-05-10 | 2023-06-21 | 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 | 2022-12-20 | 2023-01-27 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-20 | 2023-01-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-17 | 2022-09-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-20 | 2022-07-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-20 | 2022-07-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-20 | 2022-07-20 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-03-16 | 2022-04-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-28 | 2021-11-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-28 | 2021-11-08 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-06-08 | 2021-06-08 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-01-20 | 2021-04-16 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-01-20 | 2021-04-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-01-26 | 2021-03-04 | 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 | 2021-01-26 | 2021-03-04 | N |
| Report COVID19 data to residents and families. | Health | 2021-01-26 | 2021-03-04 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-02-07 | 2019-03-19 | 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 | 2019-02-07 | 2019-03-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-07 | 2019-03-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-07 | 2019-03-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-02-07 | 2019-03-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-07 | 2019-03-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-07 | 2019-03-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-07 | 2019-03-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-07 | 2019-03-19 | N |
| Dispose of garbage and refuse properly. | Health | 2019-02-07 | 2019-03-19 | N |
