Deficiency Records for Avera Mother Joseph Manor Retirement Community
Updated as of March 01, 2024
A list of the most recent deficiencies for Avera Mother Joseph Manor Retirement Community. 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? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2023-08-02 | 2023-09-18 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-23 | 2023-04-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-23 | 2023-04-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-23 | 2023-04-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-23 | 2023-04-21 | 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 | 2023-03-23 | 2023-04-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-23 | 2023-04-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-23 | 2023-04-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-26 | 2021-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-26 | 2021-12-15 | 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 | 2021-10-28 | 2021-12-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-01 | 2019-06-04 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2019-05-02 | 2019-05-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-05-02 | 2019-05-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-05-02 | 2019-05-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-02 | 2019-05-05 | N |
