A list of the most recent deficiencies for Burleson St Joseph Manor. 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 properly protected cooking facilities. | Fire Safety | 2023-02-03 | 2023-02-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-03 | 2023-02-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-03 | 2023-02-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-18 | 2022-11-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-14 | 2022-08-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-16 | 2022-07-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-09 | 2022-07-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-09 | 2022-07-08 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-06-09 | 2022-07-08 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-06-09 | 2022-07-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-09 | 2022-07-08 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-05-13 | 2022-05-24 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-04-13 | 2022-05-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-11 | 2022-04-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-13 | 2021-11-20 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-05-29 | 2019-07-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-29 | 2019-07-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-05-29 | 2019-07-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-05-29 | 2019-07-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-30 | 2019-07-01 | 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 | 2019-05-30 | 2019-07-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-30 | 2019-07-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-05-30 | 2019-07-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-30 | 2019-07-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-30 | 2019-07-01 | 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 | 2018-05-10 | 2018-06-15 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2018-05-10 | 2018-06-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-05-10 | 2018-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-10 | 2018-06-15 | 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 | 2018-05-10 | 2018-06-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-05-10 | 2018-06-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-05-10 | 2018-06-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-10 | 2018-05-29 | N |
