Deficiency Records for Saint Joseph of The Pines Health Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Saint Joseph of The Pines Health 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-08 | 2023-08-18 | 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 | 2023-06-08 | 2023-08-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-08 | 2023-08-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-08 | 2023-08-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-08 | 2023-08-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-08 | 2023-08-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-08 | 2023-08-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-08 | 2023-08-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-05 | 2023-04-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-05 | 2023-04-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-14 | 2021-08-20 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-07-14 | 2021-08-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-07-14 | 2021-08-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-14 | 2021-08-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-14 | 2021-08-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-14 | 2021-08-20 | 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 | 2021-07-14 | 2021-08-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-14 | 2021-08-20 | 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 | 2019-06-19 | 2019-08-03 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-06-19 | 2019-08-03 | 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 | 2019-06-19 | 2019-08-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-19 | 2019-08-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-19 | 2019-08-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-19 | 2019-08-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-19 | 2019-08-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-02 | 2019-05-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-02 | 2019-05-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-02 | 2019-05-30 | 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 | 2019-05-02 | 2019-05-30 | 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 | 2019-05-02 | 2019-05-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-02 | 2019-05-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-05-02 | 2019-05-30 | N |
