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Deficiency Records for Ascension Saint Anne Place
A list of the most recent deficiencies for Ascension Saint Anne Place. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Ascension Saint Anne Place. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2024-08-23 | 2024-09-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-08-23 | 2024-09-11 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2024-08-23 | 2024-09-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-08-23 | 2024-09-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-08-23 | 2024-09-11 | 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 | 2024-08-23 | 2024-09-11 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-08-23 | 2024-09-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-23 | 2024-09-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-23 | 2024-09-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-23 | 2024-09-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-08-23 | 2024-09-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-23 | 2024-09-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-08-23 | 2024-09-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-07 | 2024-08-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-07 | 2024-08-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-07 | 2024-08-14 | 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 | 2024-08-07 | 2024-08-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-07 | 2024-08-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-08-07 | 2024-08-08 | 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 | 2024-08-07 | 2024-08-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-17 | 2024-07-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-04-03 | 2024-04-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-13 | 2024-03-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-13 | 2024-03-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-21 | 2024-02-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-15 | 2023-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-15 | 2023-11-16 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-26 | 2023-09-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-07-26 | 2023-08-09 | 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 | 2023-07-26 | 2023-08-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-26 | 2023-08-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-26 | 2023-08-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-26 | 2023-08-04 | N |
| Use approved construction type or materials. | Fire Safety | 2023-07-26 | 2023-08-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-07-26 | 2023-08-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-07-26 | 2023-08-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-26 | 2023-08-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-26 | 2023-07-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-13 | 2023-07-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-13 | 2023-07-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-13 | 2023-07-28 | 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 | 2023-07-13 | 2023-07-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-13 | 2023-07-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-13 | 2023-07-28 | 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 | 2023-07-13 | 2023-07-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-07-13 | 2023-07-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-21 | 2023-02-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-26 | 2023-02-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-26 | 2023-02-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-26 | 2023-02-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-28 | 2023-02-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-26 | 2022-11-10 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-25 | 2022-08-06 | Y |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-05-31 | 2022-07-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-06 | 2022-07-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-22 | 2022-06-30 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-31 | 2022-06-20 | 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 | 2022-05-31 | 2022-06-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-05-31 | 2022-06-20 | 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 | 2022-05-31 | 2022-06-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-05-23 | 2022-06-01 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-05-12 | 2022-05-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-12 | 2022-05-28 | 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 | 2022-05-12 | 2022-05-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-12 | 2022-05-28 | 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 | 2022-05-12 | 2022-05-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-12 | 2022-05-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-12 | 2022-05-28 | N |
| Keep all essential equipment working safely. | Health | 2022-05-12 | 2022-05-28 | N |
| Respond appropriately to all alleged violations. | Health | 2021-10-25 | 2021-10-27 | Y |
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