A list of the most recent deficiencies for St Anne's Salvatorian Campus. 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? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-17 | 2023-09-13 | 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 | 2023-08-17 | 2023-09-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-17 | 2023-09-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-17 | 2023-09-13 | N |
| Provide appropriate foot care. | Health | 2023-08-17 | 2023-09-13 | 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 | 2023-08-17 | 2023-09-13 | 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 | 2023-08-17 | 2023-09-13 | 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 | 2023-08-17 | 2023-09-13 | 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 | 2023-08-17 | 2023-09-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-17 | 2023-09-13 | 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 | 2023-08-17 | 2023-09-13 | 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 | 2023-08-17 | 2023-09-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-17 | 2023-09-13 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-08-17 | 2023-09-13 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-08-17 | 2023-09-13 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-08-17 | 2023-09-13 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-08-17 | 2023-09-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-17 | 2023-09-13 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-17 | 2023-09-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-17 | 2023-09-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-17 | 2023-09-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-17 | 2023-09-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-17 | 2023-09-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-17 | 2023-09-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-17 | 2023-09-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-17 | 2023-09-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-17 | 2023-09-13 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-08-17 | 2023-09-13 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-17 | 2023-09-13 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-08-17 | 2023-09-13 | Y |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2023-08-18 | 2023-08-25 | 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 | 2023-08-18 | 2023-08-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-18 | 2023-08-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-18 | 2023-08-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-18 | 2023-08-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-18 | 2023-08-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-12 | 2022-11-09 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-08 | 2022-08-06 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-06-08 | 2022-07-05 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-08 | 2022-07-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-08 | 2022-07-05 | 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 | 2022-06-08 | 2022-07-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-08 | 2022-07-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-08 | 2022-07-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-08 | 2022-07-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-08 | 2022-07-01 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-02 | 2022-04-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-08 | 2021-08-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-24 | 2021-05-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-24 | 2021-05-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-24 | 2021-05-12 | 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 | 2021-03-24 | 2021-05-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-03-24 | 2021-05-12 | 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 | 2021-03-24 | 2021-05-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-24 | 2021-05-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-03-24 | 2021-05-12 | N |
