A list of the most recent deficiencies for Mount Saint Joseph 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-05 | 2023-10-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-05 | 2023-10-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-11 | 2023-05-03 | 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 | 2022-08-04 | 2022-09-19 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-08-04 | 2022-09-19 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-02 | 2022-09-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-02 | 2022-09-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-02 | 2022-09-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-10 | 2021-09-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-29 | 2019-09-25 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-08-29 | 2019-09-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-29 | 2019-09-25 | 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 | 2019-08-29 | 2019-09-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-29 | 2019-09-25 | N |
| Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. | Health | 2019-08-29 | 2019-09-25 | 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 | 2019-08-29 | 2019-09-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-29 | 2019-09-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-07-26 | 2018-08-24 | 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 | 2018-07-26 | 2018-08-24 | N |
| Respond appropriately to all alleged violations. | Health | 2018-07-26 | 2018-08-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-26 | 2018-08-24 | 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 | 2018-07-26 | 2018-08-24 | N |
| Provide or obtain dental services for each resident. | Health | 2018-07-26 | 2018-08-24 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-07-25 | 2018-08-24 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-07-25 | 2018-08-24 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-07-25 | 2018-08-24 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2018-07-25 | 2018-08-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-07-25 | 2018-08-24 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-07-25 | 2018-08-24 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-07-25 | 2018-08-24 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-07-25 | 2018-08-24 | 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 | 2018-07-25 | 2018-08-24 | 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 | 2018-07-25 | 2018-08-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-07-25 | 2018-08-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-25 | 2018-08-24 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-07-25 | 2018-08-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-07-25 | 2018-08-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-07-25 | 2018-08-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-07-25 | 2018-08-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-07-25 | 2018-08-24 | N |
