A list of the most recent deficiencies for Ascension Saint Joseph Village. 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? |
|---|---|---|---|---|
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-11-09 | 2023-11-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-01 | 2023-11-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-10 | 2023-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-06 | 2023-07-31 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-05-10 | 2023-06-06 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-11 | 2023-04-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-11 | 2023-04-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-11 | 2023-04-26 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2023-04-11 | 2023-04-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-29 | 2023-04-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-29 | 2023-04-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-29 | 2023-04-22 | 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 | 2023-03-29 | 2023-04-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-29 | 2023-04-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-29 | 2023-04-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-29 | 2023-04-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-29 | 2023-04-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-22 | 2023-04-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-22 | 2023-04-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-09 | 2023-04-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-17 | 2023-02-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-17 | 2023-02-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-17 | 2023-02-06 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-17 | 2023-02-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-06 | 2022-10-07 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-02-24 | 2022-03-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-16 | 2022-03-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-16 | 2022-03-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-16 | 2022-03-04 | 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 | 2022-02-16 | 2022-03-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-16 | 2022-03-04 | 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 | 2022-02-16 | 2022-03-04 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-02-16 | 2022-03-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-16 | 2022-03-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-16 | 2022-03-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-24 | 2022-03-03 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2022-02-24 | 2022-02-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-02-24 | 2022-02-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-24 | 2022-02-25 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-02-24 | 2022-02-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-24 | 2022-02-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-11 | 2022-01-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-11 | 2021-08-31 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-05-14 | 2021-06-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-05-14 | 2021-06-14 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-05-14 | 2021-06-14 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-05-14 | 2021-06-14 | N |
| Establish methods for sharing information. | Fire Safety | 2021-05-14 | 2021-06-14 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-05-14 | 2021-06-14 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-05-14 | 2021-06-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-05-14 | 2021-06-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-14 | 2021-06-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-14 | 2021-06-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-29 | 2021-05-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-29 | 2021-05-17 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-04-29 | 2021-05-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-29 | 2021-05-17 | 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 | 2021-04-29 | 2021-05-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-04-29 | 2021-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-29 | 2021-05-17 | N |
