A list of the most recent deficiencies for St Johns On Fountain Lake. 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? |
|---|---|---|---|---|
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-11 | 2024-02-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-11 | 2024-02-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-11 | 2024-02-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-11 | 2024-02-08 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-01-10 | 2024-02-05 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-01-10 | 2024-02-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-10 | 2024-02-05 | 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 | 2024-01-10 | 2024-02-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-10 | 2024-02-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-10 | 2024-02-05 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-09-20 | 2023-10-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-20 | 2023-10-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-07 | 2023-09-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-09 | 2023-03-31 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-09 | 2023-03-31 | 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 | 2023-03-09 | 2023-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-09 | 2023-03-31 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-03-09 | 2023-03-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-09 | 2023-03-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-06 | 2023-03-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-06 | 2023-03-31 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-03-06 | 2023-03-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-06 | 2023-03-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-06 | 2023-03-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-06 | 2023-03-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-06 | 2023-03-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-28 | 2022-01-27 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-11-17 | 2021-09-30 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-05-26 | 2021-08-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-01 | 2021-07-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-01 | 2021-07-01 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-06-01 | 2021-07-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-01 | 2021-07-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-01 | 2021-06-30 | 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 | 2021-06-01 | 2021-06-30 | 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 | 2021-06-01 | 2021-06-30 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-06-01 | 2021-06-30 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-06-01 | 2021-06-30 | Y |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-05-26 | 2021-05-26 | N |
