A list of the most recent deficiencies for Johnson Memorial Hosp and 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? |
|---|---|---|---|---|
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-06-01 | 2023-07-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-01 | 2023-07-24 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-06-01 | 2023-07-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-01 | 2023-07-23 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-01 | 2023-07-15 | 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 | 2023-06-01 | 2023-07-07 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-06-01 | 2023-07-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-30 | 2023-06-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-01 | 2023-06-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-02 | 2023-05-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-09 | 2022-03-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-09 | 2022-03-25 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-26 | 2021-10-11 | 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 | 2021-08-26 | 2021-10-08 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-08-26 | 2021-10-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-26 | 2021-09-29 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2021-08-26 | 2021-09-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-26 | 2021-09-27 | 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 | 2021-08-26 | 2021-09-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-26 | 2021-08-31 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-08-26 | 2021-08-27 | N |
| 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 | 2021-08-26 | 2021-08-27 | N |
| Report COVID19 data to residents and families. | Health | 2021-08-26 | 2021-08-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-10 | 2021-06-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-10 | 2021-06-14 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-05-10 | 2021-06-14 | Y |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2019-09-24 | 2019-11-30 | 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 | 2019-09-24 | 2019-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-24 | 2019-11-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-24 | 2019-11-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-24 | 2019-11-01 | 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 | 2019-09-26 | 2019-10-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-26 | 2019-10-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-26 | 2019-10-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-26 | 2019-10-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-26 | 2019-10-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-24 | 2019-10-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-24 | 2019-10-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-09-26 | 2019-09-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-24 | 2019-09-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-24 | 2019-09-24 | N |
