A list of the most recent deficiencies for Providence St Joseph 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-05 | 2023-06-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-10 | 2023-03-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-20 | 2022-10-10 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-20 | 2022-10-10 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-08-04 | 2022-08-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-15 | 2022-05-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-15 | 2022-05-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-15 | 2022-05-06 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-04-15 | 2022-05-06 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-01-13 | 2022-02-07 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-01-13 | 2022-02-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-13 | 2022-02-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-01-13 | 2022-02-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-07 | 2022-02-07 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-01-12 | 2022-01-31 | N |
| Meet other general requirements. | Fire Safety | 2022-01-12 | 2022-01-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-12 | 2022-01-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-12 | 2022-01-27 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-06-07 | 2021-06-28 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-04-02 | 2021-05-01 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-04-02 | 2021-05-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-02 | 2021-05-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-02 | 2021-05-01 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-02-21 | 2019-04-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-02-21 | 2019-04-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-21 | 2019-04-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-21 | 2019-04-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-02-21 | 2019-04-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-21 | 2019-04-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-21 | 2019-04-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-02-21 | 2019-04-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-21 | 2019-04-01 | N |
| Provide activities to meet all resident's needs. | Health | 2019-02-21 | 2019-04-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-21 | 2019-04-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-02-21 | 2019-04-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-02-21 | 2019-04-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-21 | 2019-04-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-02-21 | 2019-04-01 | 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 | 2019-02-21 | 2019-04-01 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-02-21 | 2019-04-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-21 | 2019-04-01 | 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 | 2019-02-21 | 2019-04-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-21 | 2019-04-01 | 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 | 2019-02-21 | 2019-04-01 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-02-21 | 2019-04-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-02-21 | 2019-04-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-21 | 2019-04-01 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-02-21 | 2019-04-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2019-02-14 | 2019-03-15 | 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 | 2017-12-21 | 2018-03-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2017-12-21 | 2018-03-06 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2017-12-21 | 2018-03-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2017-12-21 | 2018-03-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-21 | 2018-03-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2017-12-21 | 2018-03-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2017-12-21 | 2018-03-06 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2017-12-21 | 2018-03-06 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2017-12-21 | 2018-03-06 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2017-12-21 | 2018-03-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2017-12-21 | 2018-03-06 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2017-12-21 | 2018-03-06 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2017-12-21 | 2018-03-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2017-12-21 | 2018-03-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2017-12-21 | 2018-03-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2017-12-21 | 2018-03-06 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Develop a communication plan. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Provide emergency officials' contact information. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Establish methods for sharing information. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Establish emergency prep training and testing. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2017-12-21 | 2018-03-06 | N |
| Have exits that are accessible at all times. | Fire Safety | 2017-12-19 | 2018-01-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-12-19 | 2018-01-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-12-19 | 2018-01-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-12-19 | 2018-01-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-12-19 | 2018-01-15 | N |
