Deficiency Records for Saints Joachim and Anne Nursing and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Saints Joachim and Anne Nursing and Rehab Center. 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 | 2023-04-25 | 2023-07-24 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2023-04-25 | 2023-07-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-04-25 | 2023-07-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-04-25 | 2023-07-05 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-04-25 | 2023-07-05 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-04-25 | 2023-07-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-25 | 2023-07-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-04-25 | 2023-07-03 | N |
| Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction. | Fire Safety | 2023-04-25 | 2023-07-03 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-04-25 | 2023-07-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-25 | 2023-07-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-25 | 2023-07-03 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-04-25 | 2023-07-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-04-25 | 2023-07-03 | 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 | 2023-04-24 | 2023-06-28 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-04-25 | 2023-06-24 | 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 | 2023-04-24 | 2023-06-16 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-04-24 | 2023-06-16 | 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 | 2023-04-24 | 2023-06-16 | 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 | 2023-04-24 | 2023-06-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-04-24 | 2023-06-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-09-15 | 2020-10-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-09-15 | 2020-10-28 | N |
| Install proper backup exit lighting. | Fire Safety | 2020-09-15 | 2020-10-28 | 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 | 2020-09-15 | 2020-10-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-09-15 | 2020-10-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-09-15 | 2020-10-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-09-15 | 2020-10-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-09-15 | 2020-09-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-14 | 2018-10-13 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-09-14 | 2018-10-13 | N |
| Develop a communication plan. | Fire Safety | 2018-09-14 | 2018-10-04 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-09-14 | 2018-10-04 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-09-14 | 2018-10-04 | 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 | 2018-09-14 | 2018-10-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-09-14 | 2018-10-04 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-09-14 | 2018-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-14 | 2018-10-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-14 | 2018-10-04 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-09-15 | Not Fixed | N |
