Deficiency Records for Saint Anne Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Saint Anne Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-15 | 2024-01-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-15 | 2024-01-26 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-15 | 2024-01-26 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-07-28 | 2023-09-08 | 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 | 2023-07-28 | 2023-09-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-28 | 2023-09-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-28 | 2023-09-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Establish methods for sharing information. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-08-02 | 2023-09-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-03 | 2022-11-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-03 | 2022-11-11 | 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 | 2022-04-27 | 2022-06-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-27 | 2022-06-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-27 | 2022-06-01 | Y |
| 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 | 2022-04-27 | 2022-06-01 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-04-27 | 2022-06-01 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-04-27 | 2022-06-01 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-27 | 2022-06-01 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-27 | 2022-06-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-27 | 2022-06-01 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-27 | 2022-06-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-27 | 2022-06-01 | Y |
| 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 | 2022-04-27 | 2022-06-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-27 | 2022-06-01 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-04-27 | 2022-06-01 | Y |
| 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 | 2022-04-27 | 2022-06-01 | Y |
| 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 | 2022-04-27 | 2022-06-01 | Y |
| Provide or obtain dental services for each resident. | Health | 2022-04-27 | 2022-06-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-27 | 2022-06-01 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-04-27 | 2022-06-01 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-04-18 | 2022-04-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-18 | 2022-04-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-18 | 2022-04-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-18 | 2022-04-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-13 | 2021-11-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-13 | 2021-11-03 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-10-13 | 2021-11-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-14 | 2021-10-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-01-23 | 2019-03-04 | N |
| Respond appropriately to all alleged violations. | Health | 2019-01-23 | 2019-03-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-01-23 | 2019-03-04 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-01-23 | 2019-03-04 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-01-23 | 2019-03-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-01-23 | 2019-03-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-23 | 2019-03-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-23 | 2019-03-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-01-23 | 2019-03-04 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-01-23 | 2019-03-04 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-01-23 | 2019-03-04 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-01-23 | 2019-03-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-23 | 2019-03-04 | 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 | 2019-01-23 | 2019-03-04 | N |
| Provide or obtain dental services for each resident. | Health | 2019-01-23 | 2019-03-04 | 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 | 2019-01-23 | 2019-03-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-23 | 2019-03-04 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-01-23 | 2019-03-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-01-23 | 2019-03-04 | 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 | 2019-01-23 | 2019-03-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-01-07 | 2019-01-25 | N |
