Deficiency Records for All Saint's Subacute and Transitional Care
Updated as of April 01, 2024
A list of the most recent deficiencies for All Saint's Subacute and Transitional Care. 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? |
|---|---|---|---|---|
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-09-29 | 2023-10-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-03 | 2023-08-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-17 | 2023-05-17 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-25 | 2022-06-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-05-25 | 2022-06-28 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-05-25 | 2022-06-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-05-25 | 2022-06-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-25 | 2022-06-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-25 | 2022-06-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-25 | 2022-06-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-25 | 2022-06-28 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2022-05-25 | 2022-06-28 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-05-25 | 2022-06-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-05-19 | 2022-06-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-19 | 2022-06-14 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-05-19 | 2022-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-20 | 2021-11-15 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-09-20 | 2021-10-15 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Use approved construction type or materials. | Fire Safety | 2020-01-09 | 2020-01-29 | 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 | 2020-01-09 | 2020-01-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-09 | 2020-01-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-21 | 2019-12-09 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-11-21 | 2019-12-09 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Develop a communication plan. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-22 | 2019-03-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-12-20 | 2019-01-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-20 | 2019-01-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-20 | 2019-01-18 | 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 | 2018-12-20 | 2019-01-18 | 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 | 2018-12-20 | 2019-01-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-20 | 2019-01-18 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-12-20 | 2019-01-18 | N |
