A list of the most recent deficiencies for Joshua Tree Post Acute. 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 | 2024-01-25 | 2024-02-16 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Use approved construction type or materials. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-10 | 2023-11-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-06 | 2023-11-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-06 | 2023-11-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-06 | 2023-11-06 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-10-06 | 2023-11-06 | 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 | 2023-10-06 | 2023-11-06 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-10-06 | 2023-11-06 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-10-06 | 2023-11-06 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-10-06 | 2023-11-06 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-10-06 | 2023-11-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-06 | 2023-11-06 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Use approved construction type or materials. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-26 | 2023-05-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-13 | 2023-05-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-13 | 2023-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-13 | 2023-05-15 | 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 | 2023-04-13 | 2023-05-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-13 | 2023-05-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-13 | 2023-05-15 | 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 | 2023-04-13 | 2023-05-15 | 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 | 2023-04-13 | 2023-05-15 | 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 | 2023-04-13 | 2023-05-15 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-04-13 | 2023-05-15 | 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 | 2023-04-13 | 2023-05-15 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-03-06 | 2023-03-10 | 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 | 2023-01-12 | 2023-01-24 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-12 | 2023-01-24 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-12-14 | 2022-12-19 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-14 | 2022-12-19 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-14 | 2022-12-19 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-17 | 2022-12-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-08 | 2022-09-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-08 | 2022-09-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-08 | 2022-09-26 | 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 | 2022-09-08 | 2022-09-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-27 | 2022-08-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-29 | 2022-07-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-27 | 2022-06-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-27 | 2022-06-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-27 | 2022-06-12 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-13 | 2022-05-17 | Y |
| 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 | 2022-02-22 | 2022-03-07 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-11-02 | 2021-12-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-02 | 2021-12-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-28 | 2021-10-06 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-28 | 2021-10-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Develop a communication plan. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Establish methods for sharing information. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Use approved construction type or materials. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-04-20 | 2021-06-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-04-09 | 2021-06-15 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-04-09 | 2021-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-09 | 2021-06-15 | 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 | 2021-04-09 | 2021-06-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-09 | 2021-05-24 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-04-09 | 2021-05-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-09 | 2021-05-24 | N |
