A list of the most recent deficiencies for Peace Care St Ann's. 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 a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-11-22 | 2023-01-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-22 | 2023-01-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-22 | 2022-12-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-22 | 2022-12-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-22 | 2022-12-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-22 | 2022-12-30 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2022-11-22 | 2022-12-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-22 | 2022-12-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-22 | 2022-12-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-22 | 2022-12-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-22 | 2022-12-20 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-11-22 | 2022-12-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-11-22 | 2022-12-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-22 | 2022-12-09 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-03-11 | 2022-03-31 | Y |
| 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 | 2020-09-24 | 2020-10-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-09-24 | 2020-10-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-26 | 2019-04-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-26 | 2019-04-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-26 | 2019-04-30 | 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 | 2019-03-26 | 2019-04-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-26 | 2019-04-30 | N |
