Deficiency Records for St Joseph Manor Health and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for St Joseph Manor Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-25 | 2023-10-08 | Y |
| 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 | 2023-05-24 | 2023-06-27 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-24 | 2023-06-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-24 | 2023-06-27 | 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 | 2022-01-03 | 2022-01-28 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-06-15 | 2021-07-30 | 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 | 2021-06-15 | 2021-07-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-06-15 | 2021-07-30 | N |
| 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 | 2021-06-15 | 2021-07-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-15 | 2021-07-30 | 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 | 2021-06-15 | 2021-07-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-06-15 | 2021-07-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-15 | 2021-07-30 | 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 | 2021-06-15 | 2021-07-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-15 | 2021-07-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-15 | 2021-07-30 | 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 | 2021-06-15 | 2021-07-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-15 | 2021-07-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-15 | 2021-07-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-15 | 2021-07-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-15 | 2021-07-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-15 | 2021-07-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-15 | 2021-07-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-15 | 2021-07-30 | 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 | 2021-06-15 | 2021-07-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-15 | 2021-07-30 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-06-15 | 2021-07-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-15 | 2021-07-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-15 | 2021-07-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-15 | 2021-07-30 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-06-15 | 2021-07-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-15 | 2021-07-30 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-06-15 | 2021-07-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-06-15 | 2021-07-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-15 | 2021-07-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-15 | 2021-07-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-27 | 2020-04-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-02-27 | 2020-04-06 | N |
| 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 | 2020-02-27 | 2020-04-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-27 | 2020-04-06 | 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 | 2020-02-27 | 2020-04-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-27 | 2020-04-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-27 | 2020-04-06 | 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 | 2020-02-27 | 2020-04-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-27 | 2020-04-06 | 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 | 2020-02-27 | 2020-04-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-27 | 2020-04-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-29 | Not Fixed | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-01-29 | Not Fixed | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2024-01-29 | Not Fixed | 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 | 2024-01-29 | Not Fixed | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-01-29 | Not Fixed | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-29 | Not Fixed | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-29 | Not Fixed | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-29 | Not Fixed | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-29 | Not Fixed | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-29 | Not Fixed | 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 | 2024-01-29 | Not Fixed | 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 | 2024-01-29 | Not Fixed | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-29 | Not Fixed | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-01-29 | Not Fixed | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-01-29 | Not Fixed | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-29 | Not Fixed | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2024-01-29 | Not Fixed | N |
| 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 | 2024-01-29 | Not Fixed | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-01-29 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-29 | Not Fixed | N |
| Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2024-01-29 | Not Fixed | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-29 | Not Fixed | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-29 | Not Fixed | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-29 | Not Fixed | N |
