Deficiency Records for St. Ann's Skilled Nursing and Therapy
Updated as of April 01, 2024
A list of the most recent deficiencies for St. Ann's Skilled Nursing and Therapy. 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-30 | 2023-06-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-30 | 2023-06-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-30 | 2023-06-21 | 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 | 2023-04-03 | 2023-05-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-03 | 2023-05-30 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-04-03 | 2023-05-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-11-13 | 2019-12-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-11-13 | 2019-12-18 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-11-13 | 2019-12-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-13 | 2019-12-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-13 | 2019-12-18 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-11-13 | 2019-12-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-13 | 2019-12-18 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-11-13 | 2019-12-18 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-11-13 | 2019-12-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-13 | 2019-12-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-13 | 2019-12-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-12-18 | 2019-01-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-18 | 2019-01-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-18 | 2019-01-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-12-18 | 2019-01-30 | 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 | 2018-12-18 | 2019-01-30 | 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 | 2018-12-18 | 2019-01-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-12-18 | 2019-01-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-18 | 2019-01-30 | 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 | 2018-12-17 | 2019-01-30 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-12-17 | 2019-01-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-17 | 2019-01-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-17 | 2019-01-30 | N |
