A list of the most recent deficiencies for Saint Johns On The Lake. 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 appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-21 | 2023-04-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-21 | 2023-03-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-21 | 2023-03-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-21 | 2023-03-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-21 | 2023-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-21 | 2023-03-27 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2023-02-17 | 2023-03-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-17 | 2023-03-22 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-02-17 | 2023-03-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-17 | 2023-03-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-02-17 | 2023-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-17 | 2023-03-22 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-02-17 | 2023-03-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-17 | 2023-03-22 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-01-25 | 2022-02-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-25 | 2022-02-19 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-01-25 | 2022-02-19 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-19 | 2022-02-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-01-19 | 2022-02-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-01-19 | 2022-02-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-19 | 2022-02-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-19 | 2022-02-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-19 | 2022-02-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-11-07 | 2019-12-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-07 | 2019-12-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-07 | 2019-12-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-07 | 2019-12-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-07 | 2019-12-05 | 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 | 2019-11-07 | 2019-12-05 | 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 | 2019-11-07 | 2019-12-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-07 | 2019-12-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-07 | 2019-12-05 | 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 | 2019-11-07 | 2019-11-07 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-11-07 | 2019-11-07 | 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 | 2019-11-07 | 2019-11-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-07 | 2019-11-07 | N |
