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Deficiency Records for St Joseph Rehab and Nursing Care Center
A list of the most recent deficiencies for St Joseph Rehab and Nursing Care Center. 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 St Joseph Rehab and Nursing Care Center. 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? |
|---|---|---|---|---|
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-07-08 | 2024-07-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-07-08 | 2024-07-29 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-27 | 2024-03-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-27 | 2024-03-13 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-09 | 2024-03-04 | N |
| 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 | 2024-02-09 | 2024-03-04 | N |
| Respond appropriately to all alleged violations. | Health | 2024-02-09 | 2024-03-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-09 | 2024-03-04 | 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 | 2024-02-09 | 2024-03-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-09 | 2024-03-04 | N |
| Provide activities to meet all resident's needs. | Health | 2024-02-09 | 2024-03-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-09 | 2024-03-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-09 | 2024-03-04 | 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 | 2024-02-09 | 2024-03-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-09 | 2024-03-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-09 | 2024-03-04 | 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 | 2024-02-09 | 2024-03-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-09 | 2024-03-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-09 | 2024-03-04 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-02-09 | 2024-03-04 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-02-09 | 2024-03-04 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-02-09 | 2024-03-04 | 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 | 2024-02-09 | 2024-03-04 | 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 | 2024-02-09 | 2024-03-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-09 | 2024-03-04 | 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 | 2024-02-09 | 2024-03-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-09 | 2024-03-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-09 | 2024-03-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-09 | 2024-03-04 | N |
| Keep all essential equipment working safely. | Health | 2023-05-24 | 2023-06-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-07 | 2023-04-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-07 | 2023-04-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-07 | 2023-04-04 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-01-16 | 2023-03-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-16 | 2023-03-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-16 | 2023-03-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-16 | 2023-03-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-16 | 2023-03-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-28 | 2023-01-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-28 | 2023-01-31 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-12-28 | 2023-01-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-28 | 2023-01-31 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-12-28 | 2023-01-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-28 | 2023-01-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-07 | 2021-07-21 | 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 | 2021-06-23 | 2021-07-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-23 | 2021-07-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-07 | 2021-07-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-07 | 2021-07-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-07 | 2021-07-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-07 | 2021-07-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-07 | 2021-07-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-07 | 2021-07-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-07 | 2021-07-12 | N |
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