A list of the most recent deficiencies for St Joe Manor. 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-12-20 | 2022-12-20 | Y |
| 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 | 2022-05-06 | 2022-06-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-06 | 2022-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-06 | 2022-06-20 | 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 | 2022-05-06 | 2022-06-20 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-05-06 | 2022-06-20 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-05-06 | 2022-06-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-05-06 | 2022-06-20 | 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 | 2022-05-06 | 2022-06-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-06 | 2022-06-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-06 | 2022-06-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-06 | 2022-06-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-05-06 | 2022-06-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-06 | 2022-06-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-06 | 2022-06-20 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-05-18 | 2022-05-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-18 | 2022-02-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-27 | 2019-10-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-27 | 2019-10-29 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-09-27 | 2019-10-29 | N |
| 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 | 2019-09-27 | 2019-10-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-27 | 2019-10-29 | 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 | 2019-09-27 | 2019-10-29 | 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 | 2019-09-27 | 2019-10-29 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-09-27 | 2019-10-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-27 | 2019-10-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-27 | 2019-10-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-27 | 2019-10-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-27 | 2019-10-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-27 | 2019-10-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-27 | 2019-10-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-27 | 2019-10-29 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2019-09-27 | 2019-10-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-27 | 2019-10-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-30 | 2018-12-28 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-11-30 | 2018-12-28 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-11-30 | 2018-12-28 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-11-30 | 2018-12-28 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-11-30 | 2018-12-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-11-30 | 2018-12-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-11-30 | 2018-12-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-11-30 | 2018-12-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-30 | 2018-12-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-30 | 2018-12-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-11-30 | 2018-12-28 | 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 | 2018-11-30 | 2018-12-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-11-30 | 2018-12-28 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-11-30 | 2018-12-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-30 | 2018-12-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-11-30 | 2018-12-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-30 | 2018-12-28 | N |
