A list of the most recent deficiencies for St John Specialty Care 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? |
|---|---|---|---|---|
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-12-06 | 2024-02-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-06 | 2024-02-04 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-12-06 | 2024-02-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-06 | 2024-02-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-06 | 2024-02-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-12-06 | 2024-02-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-01 | 2024-01-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-12-01 | 2024-01-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-01 | 2024-01-19 | N |
| Respond appropriately to all alleged violations. | Health | 2023-12-01 | 2024-01-19 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-12-01 | 2024-01-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-01 | 2024-01-19 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-12-01 | 2024-01-19 | 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 | 2023-12-01 | 2024-01-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-01 | 2024-01-19 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-12-01 | 2024-01-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2024-01-19 | N |
| Report COVID19 data to residents and families. | Health | 2023-12-01 | 2024-01-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-20 | 2023-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-20 | 2023-08-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-20 | 2023-08-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-20 | 2023-08-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-20 | 2023-08-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-20 | 2023-08-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-20 | 2023-08-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-20 | 2023-08-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-06-20 | 2023-08-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-16 | 2023-07-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-16 | 2023-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-16 | 2023-07-28 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-06-16 | 2023-07-28 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-06-16 | 2023-07-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-23 | 2023-04-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-23 | 2023-04-21 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-23 | 2023-04-21 | Y |
| 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 | 2022-07-12 | 2022-09-10 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-07-12 | 2022-09-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-12 | 2022-09-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-12 | 2022-09-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-12 | 2022-09-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-12 | 2022-09-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-12 | 2022-09-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-08 | 2022-08-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-07-08 | 2022-08-19 | N |
| Respond appropriately to all alleged violations. | Health | 2022-07-08 | 2022-08-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-08 | 2022-08-19 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-07-08 | 2022-08-19 | N |
| Provide activities to meet all resident's needs. | Health | 2022-07-08 | 2022-08-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-08 | 2022-08-19 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-07-08 | 2022-08-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-08 | 2022-08-19 | 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 | 2022-07-08 | 2022-08-19 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-07-08 | 2022-08-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-08 | 2022-08-19 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-07-08 | 2022-08-19 | N |
