A list of the most recent deficiencies for St Johns Place. 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? |
|---|---|---|---|---|
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-26 | 2024-01-12 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-26 | 2024-01-08 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-12-26 | 2024-01-08 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-10-25 | 2022-11-18 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-10-25 | 2022-11-16 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-10-25 | 2022-11-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-25 | 2022-11-15 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-03-03 | 2022-04-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-03-03 | 2022-04-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-03 | 2022-04-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-03 | 2022-04-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-03-03 | 2022-04-01 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-03-03 | 2022-04-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-03 | 2022-04-01 | 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 | 2022-03-03 | 2022-04-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-03-03 | 2022-03-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-03 | 2022-03-21 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-07-28 | 2021-08-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-28 | 2021-08-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-28 | 2021-08-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-28 | 2021-08-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-28 | 2021-08-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-28 | 2021-08-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-28 | 2021-08-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-28 | 2021-08-17 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-07-28 | 2021-08-17 | 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 | 2021-07-28 | 2021-08-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-07-28 | 2021-08-16 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-07-28 | 2021-08-16 | 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 | 2021-07-28 | 2021-08-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-28 | 2021-08-16 | 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 | 2021-07-28 | 2021-08-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-07-28 | 2021-08-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-28 | 2021-08-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-28 | 2021-08-14 | 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 | 2021-07-28 | 2021-08-14 | 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 | 2021-07-28 | 2021-08-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-28 | 2021-07-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-28 | 2021-07-28 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-07-28 | 2021-07-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-28 | 2021-07-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-20 | 2021-05-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-20 | 2021-05-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-20 | 2021-05-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-20 | 2021-05-20 | 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 | 2019-09-13 | 2020-09-02 | 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 | 2019-09-13 | 2019-10-11 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-09-13 | 2019-10-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-13 | 2019-10-10 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-09-13 | 2019-10-07 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-09-13 | 2019-10-07 | N |
| Post nurse staffing information every day. | Health | 2019-09-13 | 2019-10-07 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2019-09-13 | 2019-10-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-13 | 2019-10-07 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-09-13 | 2019-10-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-13 | 2019-10-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-13 | 2019-10-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-13 | 2019-10-07 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-09-13 | 2019-10-07 | 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 | 2019-09-13 | 2019-09-13 | N |
