A list of the most recent deficiencies for St Joseph's Manor. 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? |
|---|---|---|---|---|
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-03-06 | 2023-05-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-06 | 2023-05-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-06 | 2023-05-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-06 | 2023-05-05 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-03-06 | 2023-05-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-06 | 2023-05-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-23 | 2023-03-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-14 | 2022-06-13 | 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 | 2022-04-14 | 2022-06-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-14 | 2022-06-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-14 | 2022-06-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-14 | 2022-06-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-14 | 2022-06-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-14 | 2022-06-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-14 | 2022-06-13 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-04-14 | 2022-06-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-14 | 2022-06-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-17 | 2022-04-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-04-19 | 2021-08-05 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-04-19 | 2021-07-16 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-04-19 | 2021-06-18 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-04-19 | 2021-06-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-19 | 2021-06-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-19 | 2021-06-18 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-04-19 | 2021-06-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-19 | 2021-06-18 | N |
| Ensure that anesthesia apparatus are tested after any adjustment, modification or repair. | Fire Safety | 2021-04-19 | 2021-06-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-04-02 | 2021-05-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-02 | 2021-05-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-02 | 2021-05-28 | 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 | 2021-04-02 | 2021-05-28 | 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 | 2021-04-02 | 2021-05-28 | N |
