A list of the most recent deficiencies for Saint John Xxiii Home. 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? |
|---|---|---|---|---|
| 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 | 2023-05-04 | 2023-05-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-10 | 2023-05-22 | 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 | 2022-06-03 | 2022-07-22 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-06-03 | 2022-07-22 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-06-07 | 2022-06-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-07 | 2022-06-24 | 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 | 2021-08-23 | 2021-09-14 | N |
| 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 | 2021-08-23 | 2021-09-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-23 | 2021-09-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-23 | 2021-09-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-23 | 2021-09-14 | 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 | 2021-08-13 | 2021-09-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-16 | 2021-08-26 | Y |
